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INTRODUCCIÓN: El retraso del procesamiento de las licencias médicas (LMs) representa un problema de salud pública en Chile, considerando que esto afecta el pago del subsidio a las personas destinado a realizar el reposo médico prescrito mientras no se pueda trabajar. El objetivo de este estudio fue explorar las diferencias en el tiempo de procesamiento de las licencias médicas electrónicas (LMEs) evaluadas por contraloría médica (CM) y las evaluadas por un sistema predictivo de contraloría médica (SPCM) basado en redes neuronales artificiales. MATERIALES Y MÉTODOS: El tiempo de procesamiento de LMEs procesadas con SPCM fue comparado con el tiempo de procesamiento de LMEs examinadas solo con CM, usando curvas de Kaplan Meier, prueba de log-rank y modelos multivariados de Cox. RESULTADOS: La tasa de procesamiento del SPCM fue entre 1,7 a 5,5 veces más rápida que la tasa de procesamiento de la CM, ajustando por potenciales confusores. DISCUSIÓN: La implementación del SPCM permitió disminuir el tiempo de procesamiento de las LMEs, beneficiando a los trabajadores afiliados al seguro público.

INTRODUCTION: The delay in the processing of sick leaves (SLs) is a public health pro-blem in Chile, considering that this affects the payment of the subsidy to the indivi-duals destined to perform the prescribed medical rest while unable to work. The aim of this study was to explore the differences in the processing time of electronic SLs (ESLs) evaluated by medical audit (MA) and the SLs evaluated by a predictive medi-cal audit system (PMAS) based on artificial neural networks. MATERIALS AND METHODS:The processing time of the ESLs that were processed by PMAS was compared with the processing time of those that were examined only by MA, using Kaplan Meier curves, log-rank test, and multivariate Cox models. RESULTS: The processing rate for PMAS was 1.7-fold to 5.5-fold faster than MA, after adjusting for potential confoun-ding variables. DISCUSSION: The implementation of the PMAS reduced the processing time of ESLs, which benefits the workers affiliated to the public insurance system in Chile. (AU)

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ANTECEDENTES: En las últimas décadas se ha producido un incremento extraordinario en la incidencia de cesáreas en todos los países desarrollados. La tasa de cesáreas en España registrada por el Ministerio de Sanidad es de 24,9%. OBJETIVO: Analizar las cesáreas en el Hospital La Inmaculada, mediante la clasificación de Robson para comparar con otros hospitales, tanto nacional como internacionalmente y establecer las intervenciones posibles para reducir la tasa de cesáreas. MÉTODOS: Se realiza una auditoría retrospectiva de cesáreas en función de la clasificación de diez grupos establecida por Robson desde el 1 enero de 2006 al 31 de diciembre de 2013. RESULTADOS: Se han analizado 9337 partos y 1507 cesáreas con un 16,14%. En la contribución al porcentaje de cesáreas en primer lugar con 25,2% corresponde a nulíparas con un feto único en presentación cefálica, de 37 semanas o más de embarazo. En segundo lugar las multíparas con al menos una cesárea previa, con un feto único en presentación cefálica, de 37 semanas o más de embarazo con 19,4%. En este grupo se ha realizado un 42,2% de cesáreas. En tercer lugar nulíparas con un feto único en presentación cefálica, de 37 semanas o más de embarazo, que han iniciado el parto de forma espontánea con 17,4%. CONCLUSIONES: El aumento de cesáreas en las últimas décadas hace necesario la realización de auditorías mediante un sistema de clasificación, como Robson, para establecer los grupos en los que es posible disminuir el número de cesáreas.

INTRODUCTION: In recent decades there has been a dramatic increase in cesarean section rate in all developed countries. The cesarean section rate in Spain, registered by the Ministry of Health was 24.9%. OBJECTIVE: To analyze cesarean section rate in Inmaculada Local Hospital, using Robson's classification to compare it with other hospitals, both at national and international level and establish potential interventions to reduce such rate. METHODS: A cesarean section rate retrospective audit was performed according to Robson's classification, from 1st January 2006 to 31st December 2013. RESULTS: 9337 deliveries and 1507 cesareans were analyzed on that period of time. The cesarean rate was 16.14%. Nulliparous women with a singleton pregnancy in cephalic presentation at 37 weeks or more and undergo a labor induction before the onset of labor represent the first group of the cesareans with 25.2% of the total. In second place comes multiparous women with at least one previous cesarean section with a singleton pregnancy in cephalic presentation, 37 weeks or more, representing 19.4% of the total cesareans. This group had a 42.2% cesarean rate. In third place (17.4%) we had nulliparous women with a singleton pregnancy in cephalic presentation, 37 weeks or more, who have started labor spontaneously. CONCLUSIONS: Increased cesarean section rate in recent years required audits using a classification system, like Robson's one, to establish the groups in which it is possible to reduce the number of cesareans.

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OBJECTIVE: To establish a structured review process to facilitate the identification of the fetal nasal bone (NB) in the first trimester ultrasound scan to improve the quality images. METHODS: We conducted a retrospective observational study in fetal NB images obtained during ultrasound exams of singleton pregnancies that underwent first trimester screening (crown-rump length 45-84 mm). When the images were obtained the examiner was not aware of the study. Audit was conducted by an examiner according criteria established by the Fetal Medicine Foundation. Fetal NB images were assessed regarding adequate magnification, mid-sagittal view and transducer held parallel to the direction of the nose. The transvaginal and transabdominal as well as anterior and posterior fetal back groups were compared using χ(2) test. RESULTS: We considered 874 fetal NB images for auditing. Fetal NB was considered present in 865 images (99%). During the audit process, we identified 72 (8.2%) cases of disagreement between examiner and auditor assessments. Disagreement was higher when image quality was poor (62 cases = 7%). Transvaginal approach performed better in the following criteria: adequate magnification (p < 0.001), midline (p < 0.001) and completely adequate (p < 0.001). CONCLUSION: A peer reviewed audit program for fetal NB is feasible in a clinical scenario. Image quality appears to play an important role in compliance to image standards audited and in agreement between examiner and auditor.

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BACKGROUND AND AIMS: Malnutrition is very prevalent in hospitals, causing physical capacity deterioration, increasing complications and raising mortality. This scenario overloads public health costs enormously. Enteral nutrition (EN) is the first option to fight against malnutrition. Nutrition support teams (NST) work combating such conditions, promoting humanization, but also analyzing the cost benefit of EN therapy. Brazil is one of the first Latin American countries to develop EN laws. Quality control it is in the core of this legal instrument, playing an essential role in NST`s task of providing care. Nowadays, tools to access quality control represent a gap in the area. The aim of this study was to develop a quality control tool, according to Brazilian law for EN Therapy regarding multidisciplinary approach, good practices, standard operating procedures, protocol implementation, proper registration and electronic health record. METHODS: A content validation method was utilized in this four stages development process: bibliographic research, expert opinion (subjective), semantic evaluation and expert opinion (objective). In the latter stage ten specialists, expressed their opinion, evaluating the tools by four different attributes: utility, simplicity, objective and low cost on a 5-point Likert scale (1-5). RESULTS: We elaborate three independent tools that together, represent the whole evaluation process, named: NST Activities, EN Preparation and EN Administration. Content Validation Index to the four different attributes ranged form 0,9 to 1. CONCLUSION: This tool had positive approval from experts and is of great value guiding hospital audits, or even serving as checklist to implement a plan on EN therapy.

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O objetivo do estudo foi descrever a implantação, estruturação e desenvolvimento da prática de auditoria farmacêutica em uma operadora de planos de saúde de Fortaleza (OPS). Trata-se de um estudo descritivo do tipo estudo de caso, em que a unidade de análise foi uma OPS localizada em Fortaleza, capital do estado do Ceará (Brasil). Foram coletados e analisados dados qualitativos e quantitativos que corresponderam ao período de 2007 a 2010. Para a implantação da área de auditoria farmacêutica foi utilizada como primeira estratégia sua formalização na Diretoria de Recursos Médicos Hospitalares e na estrutura organizacional da OPS em janeiro de 2007. Com o reconhecimento do trabalho desenvolvido pela área, a equipe chegou em 2010 com dois farmacêuticos, dois assistentes de farmácia e cinco estagiários. O desenvolvimento da prática de auditoria farmacêutica resultou na exigência de pareceres técnicos para inclusão de medicamentos em tabela definida pela OPS e de solicitação para medicamentos de alto custo e de reserva terapêutica. A intervenção do farmacêutico, em seis meses de experiência, junto a pacientes em uso de antimicrobianos mostrou uma economia de R$ 279.153,80. A gestão de quimioterápicos resultou em uma economia total de R$ 2.502.278,31 para a OPS em 2009. Embora a auditoria farmacêutica envolva uma discussão recente, é preciso desde já, que aspectos relacionados à sua implantação, estruturação e desenvolvimento sejam apoiados, uma vez que essa prática ajuda na descrição e análise de elementos assistenciais e de gestão que envolve pacientes em tratamento farmacológico.

The purpose of this study was to describe the implantation, organization and development of pharmaceutical audit in a health insurance provider (HIP) in northeast Brazil. This is a descriptive case study in which the unit of analysis was an HIP located n Fortaleza, capital of Ceará State. Qualitative and quantitative data covering the period from 2007 and 2010 were collected and analyzed. In order to create the pharmaceutical auditing team, the first strategy used was to set up a section in the Hospital Medical Resources Directorate and in the managerial structure of the HIP, in January 2007. With the recognition of the work developed by the section, the team was amplified in 2010 with the arrival of two pharmacists, two pharmacy assistants and five trainees. The development of the practical aspects of pharmaceutical auditing revealed a need for technical opinions on the inclusion of medicines in the table defined by the HIP and requests for authorization in the case of high-cost medicines and those used in reserved therapy. The pharmacist’s intervention, over a six-month period, in the treatment of patients with antibiotics, yielded savings of R$ 279,153.80. The management of chemotherapy resulted in total savings of R$ 2,502,278.31 for the HIP in 2009. Although pharmaceutical auditing has only come out in recent discussions, there is an immediate need to support actions related to its implantation, organization and development, since this practice helps in describing and analyzing the healthcare and management features that involve patients under pharmacological treatment.

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Social audits are typically observational studies, combining qualitative and quantitative uptake of evidence with consultative interpretation of results. This often falters on issues of causality because their cross-sectional design limits interpretation of time relations and separation out of other indirect associations.Social audits drawing on methods of randomised controlled cluster trials (RCCT) allow more certainty about causality. Randomisation means that exposure occurs independently of all events that precede it--it converts potential confounders and other covariates into random differences. In 2008, CIET social audits introduced randomisation of the knowledge translation component with subsequent measurement of impact in the changes introduced. This "proof of impact" generates an additional layer of evidence in a cost-effective way, providing implementation-ready solutions for planners.Pipeline planning is a social audit that incorporates stepped wedge RCCTs. From a listing of districts/communities as a sampling frame, individual entities (communities, towns, districts) are randomly assigned to waves of intervention. Measurement of the impact takes advantage of the delay occasioned by the reality that there are insufficient resources to implement everywhere at the same time. The impact in the first wave contrasts with the second wave, which in turn contrasts with a third wave, and so on until all have received the intervention. Provided care is taken to achieve reasonable balance in the random allocation of communities, towns or districts to the waves, the resulting analysis can be straightforward.Where there is sufficient management interest in and commitment to evidence, pipeline planning can be integrated in the roll-out of programmes where real time information can improve the pipeline. Not all interventions can be randomly allocated, however, and random differences can still distort measurement. Other issues include contamination of the subsequent waves, ambiguity of indicators, "participant effects" that result from lack of blinding and lack of placebos, ethics and, not least important, the skills to do pipeline planning correctly.

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Los scores son una herramienta de uso habitual en medicina, su finalidad brindar un resultado, que cuantifique un proceso, y ayude al diagnóstico de una patología, o al pronóstico, orientando al médico en la toma de decisiones. Aunque las internaciones hospitalarias más frecuentes con en sala común no existen scores para predecir mortalidad en ese sector. La auditoria hospitalaria demanda planificación de disposicione de camas. Los Grupos Relacionados al Diagnóstico (GRD), se basan en el diagnóstico de ingreso, pero no hay un score para predecir días de estancia en salaque no dependa del diagnóstico. Además a veces pacientes ingresados a sala tienen mala evolución y necesitan trasladarse a la unidad de cuidados intensivos (UTI). Tampoco existen scores para predecir que pacientes presentan este riesgo. OBJETIVO: elagborar scores en adultos que ingresan de manera no programada a sala común que predigan el riesgo de mortalidad, días de estancia y la necesidad de pasar de una internación en sala a cuidados críticos. METODOS: Se evaluaron pacientes mayores de 18 años, que ingresaron para internación por más de 14 horas, por patologías médicas o quirúrgicas, no programada a sala común del Hospital Italiano Córdoba. Se valoraron 53 varieables (antecedentes patológicos, tócivos, variables fisiológicas, datos demográficos, laboratorios, necesidad de oxigenoterapia, datos sociales, servicio de cabecera, grado nitricional y funcional) recabadas al ingreso.

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Los scores son una herramienta de uso habitual en medicina, su finalidad brindar un resultado, que cuantifique un proceso, y ayude al diagnóstico de una patología, o al pronóstico, orientando al médico en la toma de decisiones. Aunque las internaciones hospitalarias más frecuentes con en sala común no existen scores para predecir mortalidad en ese sector. La auditoria hospitalaria demanda planificación de disposicione de camas. Los Grupos Relacionados al Diagnóstico (GRD), se basan en el diagnóstico de ingreso, pero no hay un score para predecir días de estancia en salaque no dependa del diagnóstico. Además a veces pacientes ingresados a sala tienen mala evolución y necesitan trasladarse a la unidad de cuidados intensivos (UTI). Tampoco existen scores para predecir que pacientes presentan este riesgo. OBJETIVO: elagborar scores en adultos que ingresan de manera no programada a sala común que predigan el riesgo de mortalidad, días de estancia y la necesidad de pasar de una internación en sala a cuidados críticos. METODOS: Se evaluaron pacientes mayores de 18 años, que ingresaron para internación por más de 14 horas, por patologías médicas o quirúrgicas, no programada a sala común del Hospital Italiano Córdoba. Se valoraron 53 varieables (antecedentes patológicos, tócivos, variables fisiológicas, datos demográficos, laboratorios, necesidad de oxigenoterapia, datos sociales, servicio de cabecera, grado nitricional y funcional) recabadas al ingreso.(AU)

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Although measuring outcomes is essential to ensuring palliative care effectiveness, there is an absence of properly validated measures in many countries. We undertook a cross-cultural adaptation and validation of the Palliative Outcome Scale (POS) into a Spanish (Argentina) language and cultural context. The methodology used a sequence of phases: 1) verification of conceptual equivalence (literature review, professional interviews, and patient focus groups); 2) multiple translations; 3) committee review; and 4) field testing. Psychometric analysis entailed evaluation of quantitative content validity, construct validity, staff and patients' ratings comparison, internal consistency, test-retest reliability, and responsiveness to change. Conceptual equivalence was achieved. Multiple changes were introduced after the translations and field testing in 65 patients and 20 professionals. Content validity was high for all but one item. Construct validity against a validated quality-of-life measure (European Organization for Research and Treatment of Cancer Quality of Life C-30) was confirmed (rho=0.74, P<0.0005). There was acceptable agreement between staff and patients (Cohen's weighted kappa >0.3) for 5/10, 8/10, and 6/9 items at each of three time-point evaluations and good correlation for all but one item (Spearman coefficient >0.7). Internal consistency was acceptable (Cronbach's alpha=0.68-0.69 and 0.66-0.73) for patient and staff ratings, respectively, and test-retest reliability showed very high agreement for every item (>0.80). The Argentine POS showed adequate responsiveness to change, although significant difference was reached for only 3 out of 10 items for patients and staff, respectively. Completion of the POS did not take more than 12 and 6 minutes for patients and staff, respectively. This study indicates that the Argentine POS is a valid and reliable measure of palliative care outcomes with advanced cancer patients.

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