Using DIALOG+ in primary care to improve quality of life and mental distress of patients with long-term physical conditions: an exploratory non-controlled study in Bosnia and Herzegovina, Colombia and Uganda

Introducción: El manejo de las condiciones físicas a largo plazo es un desafío a nivel mundial, absorbiendo un recursos mayoritarios a pesar de la importancia de los cuidados intensivos. El manejo de estas condiciones se realiza en gran medida en la atención primaria, por lo que las intervenciones para mejorar la atención primaria podrían tener un impacto enorme. Sin embargo, existen muy pocos datos sobre cómo hacer esto. La angustia mental es frecuentemente comórbida con problemas a largo plazo. condiciones físicas y puede afectar el comportamiento y la adherencia a la salud, lo que lleva a peores resultados. DIALOG+ es una intervención de bajo costo, centrada en el paciente y centrada en soluciones, que se utiliza en reuniones rutinarias entre pacientes y médicos y se ha demostrado que mejora los resultados en la atención de salud mental. Surge la pregunta sobre si también podría utilizarse en atención primaria para mejorar la calidad de vida y la salud mental de los pacientes. Pacientes con condiciones físicas de larga duración. Esto es particularmente importante para los países de ingresos bajos y medios. Países con recursos sanitarios limitados. Métodos: Se realizó un ensayo exploratorio no controlado en múltiples sitios en Bosnia y Herzegovina, Colombia y Uganda. La viabilidad se determinó mediante el reclutamiento, la retención y la finalización de la sesión. Los resultados de los pacientes (calidad de vida, síntomas de ansiedad y depresión, situación social objetiva) fueron evaluado al inicio y después de tres sesiones DIALOG+ aproximadamente mensuales. Resultados: Se inscribieron en el estudio un total de 117 pacientes, 25 en Bosnia y Herzegovina, 32 en Colombia, y 60 en Uganda. En cada país, se reclutó a más del 75% de los participantes previstos, con Tasas de retención superiores al 90% y finalización de la intervención superior al 92%. Los pacientes tenían significativamente mayor calidad de vida y menos síntomas de ansiedad y depresión en el seguimiento posterior a la intervención, con tamaños de efecto moderados a grandes. No hubo mejoras significativas en la situación social objetiva. Conclusión: Los hallazgos de este ensayo exploratorio sugieren que DIALOG+ es factible en atención primaria. entornos para pacientes con condiciones físicas a largo plazo y puede mejorar sustancialmente los resultados de los pacientes. Las investigaciones futuras pueden probar la implementación y eficacia de DIALOG+ en ensayos controlados aleatorios en entornos más amplios de atención primaria en países de ingresos bajos y medianos.Q1Introduction: The management of long-term physical conditions is a challenge worldwide, absorbing a majority resources despite the importance of acute care. The management of these conditions is done largely in primary care and so interventions to improve primary care could have an enormous impact. However, very little data exist on how to do this. Mental distress is frequently comorbid with long term physical conditions, and can impact on health behaviour and adherence, leading to poorer outcomes. DIALOG+ is a low-cost, patient-centred and solution-focused intervention, which is used in routine patientclinician meetings and has been shown to improve outcomes in mental health care. The question arises as to whether it could also be used in primary care to improve the quality of life and mental health of patients with long-term physical conditions. This is particularly important for low- and middle-income countries with limited health care resources. Methods: An exploratory non-controlled multi-site trial was conducted in Bosnia and Herzegovina, Colombia, and Uganda. Feasibility was determined by recruitment, retention, and session completion. Patient outcomes (quality of life, anxiety and depression symptoms, objective social situation) were assessed at baseline and after three approximately monthly DIALOG+ sessions. Results: A total of 117 patients were enrolled in the study, 25 in Bosnia and Herzegovina, 32 in Colombia, and 60 in Uganda. In each country, more than 75% of anticipated participants were recruited, with retention rates over 90% and completion of the intervention exceeding 92%. Patients had significantly higher quality of life and fewer anxiety and depression symptoms at post-intervention follow-up, with moderate to large effect sizes. There were no significant improvements in objective social situation. Conclusion: The findings from this exploratory trial suggest that DIALOG+ is feasible in primary care settings for patients with long-term physical conditions and may substantially improve patient outcomes. Future research may test implementation and effectiveness of DIALOG+ in randomized controlled trials in wider primary care settings in low- and middle-income countries.Revista Internacional - IndexadaS

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030