Linking quality of healthcare and health-related quality of life of patients with type 2 diabetes: an evaluative study in Mexican family practice

Objective

To assess the association between quality of care and health-related quality of life among type 2 diabetes patients.

Design

A cross-sectional study assessing the association between quality of care and quality of life using multiple linear regression analysis.

Setting

Family medicine clinics (FMC) (n = 39) of the Mexican Institute of Social Security (IMSS) in Mexico City.

Participants

Type 2 diabetes patients (n = 312), older than 19 years.

Main Outcome Measure(s)

Health-related quality of life was measured using the MOS Short-Form-12 (SF-12); quality of healthcare was measured as the percentage of recommended care received under each of four domains: early detection of diabetes complications, non-pharmacological treatment, pharmacological treatment and health outcomes.

Results

The average quality of life score was 41.4 points on the physical component and 47.9 points on the mental component. Assessment of the quality of care revealed deficiencies. The average percentages of recommended care received were 21.9 for health outcomes and 56.6 for early detection of diabetes complications and pharmacological treatment; for every 10 percent additional points on the pharmacological treatment component, quality of life improved by 0.4 points on the physical component (coefficient 0.04, 95% confidence intervals 0.01–0.07).

Conclusions

There was a positive association between the quality of pharmacological care and the physical component of quality of life. The quality of healthcare for type 2 diabetes patients in FMC of the IMSS in Mexico City is not optimal.

Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study

BACKGROUND

We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities.

METHODS

In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios.

RESULTS

From May 1, 2010, to Dec 31, 2011, we included 314,623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]).

INTERPRETATION

High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy.

FUNDING

UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

Adaptación y validación de escalas de autoeficacia y empoderamiento dirigidas a mujeres mexicanas en etapa de climaterio

Objetivo. Adaptar y validar en español de México dos escalas: autoeficacia (EAE) y empoderamiento (EE) durante el climaterio. Material y métodos. El estudio se realizó de febrero a julio de 2011, en dos clínicas de medicina familiar en la Ciudad de México. Adaptación a través de pruebas piloto para comprensión lingüística; validación de constructo mediante análisis de factores con factorización del eje principal y rotación oblimin; estimación de la consistencia interna mediante alfa de Cronbach (AC). Resultados. Participaron 380 mujeres de 45 a 59 años. EAE tenía 16 reactivos con cuatro factores: participación en la relación médico-paciente; control sobre salud mental y cambios sexuales; riesgo de morir de cáncer y otros riesgos de salud, que explicaron 39.8% de variabilidad; AC= 0.84. EE: ocho reactivos con un factor que explicó 47.1% de variabilidad; AC= 0.83. Conclusión. Ambas escalas poseen características psicométricas aceptables para utilizarlas en intervenciones para mejorar el autocuidado de la salud durante el climaterio.

[Adaptation and validation of scales to measure self-efficacy and empowerment for self-care in Mexican climacteric stage women]

OBJECTIVE

To adapt and validate in Spanish of Mexico scales to measure self-efficacy (SES) and empowerment for self-care (ES) among climacteric women.

MATERIALS AND METHODS

The study was conducted from February to July 2011 in two family medicine clinics in Mexico City. The adaptation phase was done through testing for language comprehension. To validate the scales we used the principal Axis factoring analysis with oblique rotation technique and estimation of Cronbach's alpha (CA).

RESULTS

Three hundred eighty women aged 45-59 years participated in the study. SES had 16 items with four factors: participation in the doctor-patient relationship; in the study control of mental health and sexual changes; risk of dying from cancer, and other health risks that explained 39.8% of the variability, CA = 0.84. ES had eight items with one factor explaining 47.1% variability; CA = 0.83.

CONCLUSION

Both scales had acceptable psychometric properties and are suitable for interventions aimed at improving self-care of climacteric women.

Percepción de los usuarios sobre la calidad de la atención ambulatoria en servicios de salud en México

Objetivo. Identificar la percepción de los usuarios de los servicios de salud ambulatorios en México sobre la calidad de atención y los factores asociados con dicha percepción. Material y métodos. De los datos obtenidos por las Encuestas Nacionales de Salud y Nutrición 2006 y 2012 se analizó la percepción de la atención recibida y de mejoría en salud después de la atención; se elaboró un modelo multivariado para identificar los factores de los servicios asociados con la percepción de mejoría. Resultados. La buena percepción de atención se elevó de 82 a 85%, y la de mejoría del estado de salud, de 79 a 81%, entre los años 2006 y 2012. La explicación sobre la enfermedad y tratamiento, la consulta sin cita previa, la oportunidad de elegir el servicio de salud y menor tiempo de espera se asociaron con la percepción de mejoría. Conclusiones. Existen avances en la calidad de atención percibida en la atención ambulatoria en México. Es necesario fortalecer estrategias organizacionales para brindar atención con mayor oportunidad y responder a las expectativas de los usuarios.

Scaling up cancer care for children without medical insurance in developing countries: The case of Mexico

BACKGROUND

In 2006, the Mexican government launched the Fund for Protection Against Catastrophic Expenditures (FPGC) to support financially healthcare of high cost illnesses. This study aimed at answering the question whether FPGC improved coverage for cancer care and to measure survival of FPGC affiliated children with cancer.

PROCEDURE

A retrospective cohort study (2006-2009) was conducted in 47 public hospitals. Information of children and adolescents with cancer was analyzed. The coverage was estimated in accordance with expected number of incident cases and those registered at FPGC. The survival was analyzed by using Kaplan-Meier survival curves and Cox proportional hazards regression modeling.

RESULTS

The study included 3,821 patients. From 2006 to 2009, coverage of new cancer cases increased from 3.3% to 55.3%. Principal diagnoses were acute lymphoblastic leukemia (ALL, 46.4%), central nervous system (CNS) tumors (8.2%), and acute myeloid leukemia (AML, 7.4%). The survival rates at 36 months were ALL (50%), AML (30.5%), Hodgkin lymphoma (74.5%), Non-Hodgkin lymphoma (40.1%), CNS tumors (32.8%), renal tumors (58.4%), bone tumors (33.4%), retinoblastoma (59.2%), and other solid tumors (52.6%). The 3-year overall survival rates varied among the regions; children between the east and south-southeast had the higher risks (hazard ratio 3.0; 95% CI: 2.3-3.9) and 2.4; 95% CI: 2.0-2.8) of death from disease when compared with those from the central region.

CONCLUSION

FPGC has increased coverage of cancer cases. Survival rates were different throughout the country. It is necessary to evaluate the effectiveness of this policy to increase access and identify opportunities to reduce the differences in survival.

[Users' perception about of quality ambulatory healthcare services in Mexico]

OBJECTIVE

To identify users' perception about ambulatory healthcare services quality and associated factors in Mexico.

MATERIALS AND METHODS

Analysis of the 2006 and 2012 National Surveys of Health and Nutrition that included users' perception of healthcare services and improvement in health status. A multivariate regression analysis allowed identifying the associated factors with the perception of improved health status.

RESULTS

Between 2006 and 2012, users' positive perception of healthcare services increased from 82 to 85%, and user report of improvement in health status increased from 79 to 81%. Health status improvement, explanations about the disease and treatment, being attended without appointment, freedom to choose the provider and short waiting time were associated with a perception of better quality of care.

CONCLUSIONS

Users' perception about the quality of care in ambulatory healthcare settings has improved, yet it is still neccessary to strengthen organizational strategies to provide healthcare when needed and to improve fulfillment of users' expectations.

Facility-based care for delivery and management of complications related to pregnancy and childbirth in Mexico

OBJECTIVE

To describe the incidence and management of severe maternal and newborn complications in selected health facilities in Mexico.

MATERIALS AND METHODS

As part of the WHO Multicountry Survey on Maternal and Newborn health, information was collected from medical records of women with deliveries and/or severe maternal complications during pregnancy or puerperium in 14 hospitals in Mexico City and the state of Guanajuato, Mexico.

RESULTS

Of 13 311 women, 157 (12 per 1 000 live births) had severe maternal complications including 4 maternal deaths. The most frequent complications were preeclampsia, postpartum hemorrhage, and chronic hypertension. Adverse perinatal outcomes were more frequent among women with severe maternal complications. A high use of uterotonics and parenteral antibiotics was found. A small proportion of women with eclampsia received magnesium sulfate.

CONCLUSION

This study provides indicators on the incidence and management of maternal and neonatal complications in Mexico, which may be useful in studying and evaluating the performance of obstetric services.

Utilization of healthcare services among children members of Medical Insurance for a New Generation

OBJECTIVE

To describe the utilization and associated factors for preventive and curative care utilization among children affiliated to the Medical Insurance for a New Generation (SMNG).

MATERIALS AND METHODS

Data from the 2009 National Survey of SMNG was analyzed.

RESULTS

The analysis represented 1,316,867 children; 25% of urban and 37.5% of rural mothers that took their children to well-child visits. Covariates associated with preventive care utilization were children <12 months, low-birth weight, history of infectious or other diseases, mother >35 years, mother's literacy level of bachelor degree, housewife, attendance at >7 antenatal care visits, and living in a rural area. Curative care: 12% attended emergency room services, 5.4% were hospitalized and 66% received ambulatory care. Covariates associated with curative care utilization: child history of frequent diseases, mother living with husband/partner, mother's literacy level of bachelor degree, attendance >7 antenatal care visits and having paid work.

CONCLUSION

It is needed to reinforce the programs encouraging mothers to seek preventive care regularly.

The Medical Insurance for a New Generation: a viable answer for the health needs of Mexican children

OBJECTIVE

To describe the Medical Insurance for a New Generation (SMNG) as key public policy aimed at improving health care services for children under the age of five years in Mexico.

MATERIALS AND METHODS

This paper analyzes interrelated aspects of public policies to provide health care to Mexican children: a) the demographic and health status of children, with emphasis on the wide disparities between children of varying demographics; b) the relationship of the main functions of a health care system: financing, equity, access and quality, with the provision of health care for children; c) the architecture of the Medical Insurance for a New Generation.

CONCLUSION

SMNG is a program that can be instrumental in lowering infant mortality and alleviating the burden of families to care for sick children by improving access, quality of care and equity.

Design of the 2009 evaluation of the Medical Insurance for a New Generation program

OBJECTIVE

To describe the mixed-method approach to evaluate the Medical Insurance for a New Generation (Seguro Médico para una Nueva Generación, SMNG).

MATERIALS AND METHODS

The program has been comprehensively evaluated. It has four key domains: 1) SMNG design; 2) children's health status and socio-demographic characteristics; 3) performance by measuring coverage, efficiency and productivity; 4) family health expenditure. Quantitative and qualitative research approaches have been used. This included reviews of existing databases and clinical charts, collection of empirical data through in-depth interviews with healthcare providers, and a nation-wide household survey.

CONCLUSION

The results should serve as baseline data of the health status of SMNG children and the current staus of the program.

Evaluating quality of care for patients with type 2 diabetes using electronic health record information in Mexico

BACKGROUND

Several low and middle-income countries are implementing electronic health records (EHR). In the near future, EHRs could become an efficient tool to evaluate healthcare performance if appropriate indicators are developed. The aims of this study are: a) to develop quality of care indicators (QCIs) for type 2 diabetes (T2DM) in the Mexican Institute of Social Security (IMSS) health system; b) to determine the feasibility of constructing QCIs using the IMSS EHR data; and c) to evaluate the quality of care (QC) provided to IMSS patients with T2DM.

METHODS

We used a three-stage mixed methods approach: a) development of QCIs following the RAND-UCLA method; b) EHR data extraction and construction of indicators; c) QC evaluation using EHR data from 25,130 T2DM patients who received care in 2009.

RESULTS

We developed 18 QCIs, of which 14 were possible to construct using available EHR data. QCIs comprised both process of care and health outcomes. Several flaws in the EHR design and quality of data were identified. The indicators of process and outcomes of care suggested areas for improvement. For example, only 13.0% of patients were referred to an ophthalmologist; 3.9% received nutritional counseling; 63.2% of overweight/obese patients were prescribed metformin, and only 23% had HbA1c <7% (or plasma glucose≤130 mg/dl).

CONCLUSIONS

EHR data can be used to evaluate QC. The results identified both strengths and weaknesses in the electronic information system as well as in the process and outcomes of T2DM care at IMSS. This information can be used to guide targeted interventions to improve QC.

Effectiveness of a medical education intervention to treat hypertension in primary care

BACKGROUND AND OBJECTIVES

In Mexico, hypertension is among the top five causes for visits to primary care clinics; its complications are among the main causes of emergency and hospital care. The present study reports the effectiveness of a continuing medical education (CME) intervention to improve appropriate care for hypertension, on blood pressure control of hypertensive patients in primary care clinics.

METHODS

A secondary data analysis was carried out using data of hypertensive patients treated by family doctors who participated in the CME intervention. The evaluation was designed as a pre-/post-intervention study with control group in six primary care clinics. The effect of the CME intervention was analysed using multiple logistic regression modelling in which the dependent variable was uncontrolled blood pressure in the post-intervention patient measurement.

RESULTS

After the CME intervention, the net reduction of uncontrolled blood pressure between stages in the intervention group was 10.3%. The model results were that being treated by a family doctor who participated in the CME intervention reduced by 53% the probability of lack of control of blood pressure; receiving dietary recommendations reduced 57% the probability of uncontrolled blood pressure. Having uncontrolled blood pressure at the baseline stage increased the probability of lack of control in 166%, and per each unit of increase in body mass index the lack of control increased 7%.

CONCLUSIONS

CME intervention improved the medical decision-making process to manage hypertension, thus increasing the probability of hypertensive patients to have blood pressure under control.

Toward healthy aging through empowering self-care during the climacteric stage

BACKGROUND

While they progress through the climacteric stage, women often develop physical and psychological health needs, calling for innovative health-care services that can be translated into preventive programs and empowerment towards self-care.

OBJECTIVE

To identify the changes in women's discourse regarding their concerns and needs about the climacteric stage and self-care after they had participated in an integrative women-centered health-care model with empowerment for self-care.

METHODS

Women's narratives during counseling group sessions were analyzed using qualitative inductive thematic analysis.

RESULTS

A total of 121 women between 45 and 59 years of age participated. At the beginning of the counseling group sessions, we identified the following themes: (1) Lack of information about changes during the climacteric stage and self-care; (2) Tradition: the climacteric stage as a taboo subject; (3) Life's changes and transitions: the complexity of the climacteric experience; (4) Stigma of menopause; (5) Relationship between the traditional gender role and the lack of self-care. At the end of the counseling group sessions, the themes were: (1) The climacteric as a natural stage; (2) Expectations for old age; (3) Empowerment and the change of awareness for self-care; (3) De-medicalization of the climacteric; (4) The richness of group work; (5) Empowerment as motivation to convey acquired knowledge.

CONCLUSION

Women in the climacteric stage require more information about their physical, psychological and social needs, as well as the potential impact on their health during old age. Empowerment during the climacteric can contribute to improving the perception about this stage as well as the importance of self-care.

Integrative health care model for climacteric stage women: design of the intervention

Background

Climacteric stage women experience significant biological, psychological and social changes. With demographic changes being observed in the growing number of climacteric stage women in Mexico, it is important to improve their knowledge about the climacteric stage and its potential associated problems, encourage their participation in screening programs, and promote the acquisition of healthy lifestyles.

At Mexican health care institutions the predominant health care model for climacteric stage women has a biomedical perspective. Medical doctors provide mostly curative services and have limited support from other health professionals. This study aims to design an integrative health care model (IHCM: bio-psycho-social, multidisciplinary and women-centered) applicable in primary care services aimed at climacteric stage women.

Methods/Design

We present the design, inclusion criteria and detailed description of an IHCM. The IHCM consists of collaborative and coordinated provision of services by a health team, which is involves a family doctor, nurse, psychologist, and the woman herself. The health team promotes the empowerment of women through individual and group counseling on the climacteric stage and health related self-care. The intervention lasts three months followed by a three-month follow-up period to evaluate the effectiveness of the model. The effectiveness of the model will be evaluated through the following aspects: health-related quality of life (HR-QoL), empowerment, self-efficacy and knowledge regarding the climacteric stage and health-related self-care activities, use of screening services, and improvement in lifestyles (regular leisure time physical activity and healthy diet).

Discussion

Participation in preventive activities should be encouraged among women in Mexico. Designing and evaluating the effectiveness of an integrative health care model for women at the climacteric stage, based on the empowerment approach and focus on health-related self-care to improve their HR-QoL is pertinent for current health conditions of this age group.

Trial registration

The study is registered at the ClinicalTrials.gov (NCT01272115).

Effects of two educational programmes aimed at improving the utilization of non-opioid analgesics in family medicine clinics in Mexico

OBJECTIVES

To develop and test two educational programmes (interactive and passive) aimed at improving family doctors' (FD) prescribing practices and patient's knowledge and use of non-opioid analgesics (NOA).

METHODS

The educational programmes were conducted in two family medicine clinics by using a three-stage approach: baseline evaluation, design, and implementation of educational activities, and post-programme evaluation. An interactive educational programme (IEP) was compared with a passive educational programme (PEP); both were participated by FDs and patients. The IEP for FDs comprised of workshops, discussion groups, in-service training and guidelines, while for patients the IEP consisted of an interactive session with a video, leaflets and a discussion. The PEP consisted in delivering the guidelines to the FDs and the leaflets to patients. The effect of the programmes on the FDs was measured through the appropriateness of prescriptions and analysed using the differences-in-differences estimator (D-in-D), and on patients through changes in self-medication and in their knowledge about the proper use and adverse events by analysing the inter- and intra-group differences before and after the programmes.

RESULTS

The IEP obtained better results to improve appropriate FDs prescription of NOA than PEP (D-in-D = 15%). Regarding the patients, the PEP group reached higher reduction of self-medication than the IEP group (13.4% vs. 9.1%); the knowledge of proper NOA use increased by 8.5% in both groups, whereas knowledge of NOA-related adverse events was better in the IEP (39.6%) than in the PEP group (9.2%).

CONCLUSIONS

The IEP was better to improve the doctors' abilities to prescribe NOAs, and both programmes improved patients' knowledge.

Strengthening preventive care programs: a permanent challenge for healthcare systems; lessons from PREVENIMSS México

BACKGROUND

In 2001, the Instituto Mexicano del Seguro Social (IMSS) carried out a major reorganization to provide comprehensive preventive care to reinforce primary care services through the PREVENIMSS program. This program divides the population into programmatic age groups that receive specific preventive services: children (0-9 years), adolescents (10-19 years), men (20-59 years), women (20-59 years) and older adults (> = 60 years). The objective of this paper is to describe the improvement of the PREVENIMSS program in terms of the increase of coverage of preventive actions and the identification of unmet needs of unsolved and emergent health problems.

METHODS

From 2003 to 2006, four nation-wide cross-sectional probabilistic population based surveys were conducted using a four stage sampling design. Thirty thousand households were visited in each survey. The number of IMSS members interviewed ranged from 79,797 respondents in 2003 to 117,036 respondents in 2006.

RESULTS

The four surveys showed a substantial increase in coverage indicators for each age group: children, completed schemes of vaccination (> 90%), iron supplementation (17.8% to 65.5%), newborn screening for metabolic disorders (60.3% to 81.6%). Adolescents, measles - rubella vaccine (52.4% to 71.4%), hepatitis vaccine (9.3% to 46.2%), use of condoms (17.9% to 59.9%). Women, measles-rubella vaccine (28.5% to 59-2%), cervical cancer screening (66.7% to 75%), breast cancer screening (> 2.1%). Men, type 2 diabetes screening (38.6% to 57.8%) hypertension screening (48-4% to 64.0%). Older adults, pneumococcal vaccine (13.2% to 24.9%), influenza vaccine (12.6% to 52.9) Regarding the unmet needs, the prevalence of anemia in children was 30% and a growing prevalence of overweight and obesity, type 2 diabetes, and hypertension was found in men, women and older adults.

CONCLUSION

PREVENIMSS showed an important increase in the coverage of preventive services and stressed the magnitude of the old and new challenges that this healthcare system faces. The unsolved problems such as anemia, and the emerging ones such as overweight, obesity, among others, point out the need to strength preventive care through designing and implementing innovative programs aimed to attain effective coverage for those conditions in which prevention obtains substandard results.

Satisfaction of patients suffering from type 2 diabetes and/or hypertension with care offered in family medicine clinics in Mexico

OBJECTIVE

To evaluate the satisfaction and the factors related to dissatisfaction in patients suffering from type 2 diabetes and/or hypertension with care offered in family medicine clinics.

MATERIAL AND METHOD

A secondary data analysis was conducted. Main outcome measures were two indices of satisfaction: family doctor-patient relationship (FDPR) and clinic organizational arrangements (OA).

RESULTS

Approximately half of patients (n=1 323) were satisfied with care. In the FDPR index the items 'kindness of the family doctor' (FD) scored high, while the lowest score was for the items: 'the FD allows the patient to give an opinion about his/her treatment,' 'the patient understands the information' and 'the FD spends enough time on the consultation.' As for satisfaction with OA, the items 'cleanliness of the clinic' and 'ease of administrative procedures' obtained the lowest scores. In the logistic regression analysis the covariate 'negative self-rated health' and 'type of institution' were associated with dissatisfaction.

CONCLUSIONS

There are aspects of the FDPR and OA that reveal dissatisfaction of patients with chronic conditions.

[Comprehensive diabetic and hypertensive patient care involving nurses working in family practice]

OBJECTIVES

To evaluate the effectiveness of involving primary care nurses in comprehensive care of patients with hypertension and diabetes mellitus type II (DM2).

METHODS

A quasi-experimental, before-and-after study was conducted, without a control group, in eight family-practice clinics. Trained nurses offered comprehensive care in conjunction with a team made up of a family doctor, a nutritionist, a social worker, and a dentist. The intervention lasted seven months and its outcome variables were changes in body mass index, fasting blood glucose, blood pressure, self-perceived health status, treatment compliance, and emergency services requests. Any change was determined by comparing the baseline to the final measurement through interviews and recording the variables of interest in a spreadsheet.

RESULTS

In all, 1 131 patients completed the follow-up, of which 44.9% were diagnosed with hypertension, 27% with DM2, and 28.1% with both conditions. The proportion of patients seen by the coordinated health teams increased; there was a rise in cases of normal weight and overweight; a decrease in the proportion of obese (P < 0.05); and an increase in hypertensives with high blood pressure (< 130/ 80mmHg) (P < 0.05). There was no change in the proportion of diabetics with high blood glucose (< 140 mg/dl); 18.2% reported improved self-perceived health status (P < 0.05); there was improved treatment compliance (P < 0.05); and a decrease in requests for emergency services at the clinics (-4.5%) and at the hospitals (-6.8%) (P < 0.05).

CONCLUSIONS

Comprehensive care for chronically ill patients through the involvement of nurses contributes to improved health outcomes in primary care.

Social network types and functional dependency in older adults in Mexico

BACKGROUND

Social networks play a key role in caring for older adults. A better understanding of the characteristics of different social networks types (TSNs) in a given community provides useful information for designing policies to care for this age group. Therefore this study has three objectives: 1) To derive the TSNs among older adults affiliated with the Mexican Institute of Social Security; 2) To describe the main characteristics of the older adults in each TSN, including the instrumental and economic support they receive and their satisfaction with the network; 3) To determine the association between functional dependency and the type of social network.

METHODS

Secondary data analysis of the 2006 Survey of Autonomy and Dependency (N = 3,348). The TSNs were identified using the structural approach and cluster analysis. The association between functional dependency and the TSNs was evaluated with Poisson regression with robust variance analysis in which socio-demographic characteristics, lifestyle and medical history covariates were included.

RESULTS

We identified five TSNs: diverse with community participation (12.1%), diverse without community participation (44.3%); widowed (32.0%); nonfriends-restricted (7.6%); nonfamily-restricted (4.0%). Older adults belonging to widowed and restricted networks showed a higher proportion of dependency, negative self-rated health and depression. Older adults with functional dependency more likely belonged to a widowed network (adjusted prevalence ratio 1.5; 95%CI: 1.1-2.1).

CONCLUSION

The derived TSNs were similar to those described in developed countries. However, we identified the existence of a diverse network without community participation and a widowed network that have not been previously described. These TSNs and restricted networks represent a potential unmet need of social security affiliates.

Quality of care and health-related quality of life of climacteric stage women cared for in family medicine clinics in Mexico

Objectives

1) To design and validate indicators to measure the quality of the process of care that climacteric stage women receive in family medicine clinics (FMC). 2) To assess the quality of care that climacteric stage women receive in FMC. 3) To determine the association between quality of care and health-related quality of life (HR-QoL) among climacteric stage women.

Methods

The study had two phases: I. Design and validation of indicators to measure the quality of care process by using the RAND/UCLA Appropriateness Method. II. Evaluation of the quality of care and its association with HR-QoL through a cross-sectional study conducted in two FMC located in Mexico City that included 410 climacteric stage women. The quality of care was measured by estimating the percentage of recommended care received (PRCR) by climacteric stage women in three process components: health promotion, screening, and treatment. The HR-QoL was measured using the Cervantes scale (0-155). The association between quality of care and HR-QoL was estimated through multiple linear regression analysis.

Results

The lowest mean of PRCR was for the health promotion component (24.1%) and the highest for the treatment component (86.6%). The mean of HR-QoL was 50.1 points. The regression analysis showed that in the treatment component, for every 10 additional points of the PRCR, the global HR-QoL improved 2.8 points on the Cervantes scale (coefficient -0.28, P < 0.0001).

Conclusion

The indicators to measure quality of care for climacteric stage women are applicable and feasible in family medicine settings. There is a positive association between the quality of the treatment component and HR-QoL; this would encourage interventions to improve quality of care for climacteric stage women.

Critical analysis of deaths due to atypical pneumonia during the onset of the influenza A (H1N1) virus epidemic

BACKGROUND

The ongoing influenza A (H1N1) pandemic stroked Mexico and posed a huge challenge to the medical care and public health systems. This report analyzes the clinical course and process of care of patients who died due to atypical pneumonia and fulfilled the clinical criteria of suspected case of novel influenza A (H1N1) virus infection.

METHODS

We conducted a retrospective analysis of a series of 38 patients who died between April 7 and April 28, 2009 at Instituto Mexicano del Seguro Social (IMSS) hospitals due to severe pneumonia and respiratory distress. These cases coincided with the beginning of the outbreak, so patients did not undergo laboratory testing to diagnose influenza. According to IMSS and CDC criteria, post-hoc analysis allowed considering the presumptive diagnosis of S-OIV infection. A multidisciplinary group analyzed the information from the clinical charts, laboratory tests, radiographic studies and death certificates, using descriptive statistics.

RESULTS

Most cases were middle-aged (mean 33 years, range: 4-62 years) and previously healthy; 18.4% had an underlying chronic disease, 23.7% were obese and 7.9% were current smokers. None had received the seasonal influenza vaccine; they had cough (92%), fever (86.8%), and malaise (73.7%). The median time from disease onset to hospital admission was 6 days (range 0-8 days). All were admitted to the intensive care unit with pneumonia and/or respiratory distress. Average time from disease onset to death was 8 days (range 4-18 days).

CONCLUSIONS

An increased number of severe cases of atypical pneumonia in previously healthy adults highlight the importance of the availability of a timely surveillance system able to identify sudden increases in the number of cases or presentation of apparently known diseases.