Análise dos resultados de saúde no infarto agudo do miocárdio: uma abordagem de saúde baseada em valor

Highlights The adoption of the prospective global payment (PGP) model represents a significant improvement in the health outcomes and cost-effectiveness of healthcare. The PGP model reduces hospitalization days and costs while maintaining or improving health outcomes for acute myocardial infarction (AMI) patients. Patients who died had longer hospital stays, especially women and those with ST-segment elevation. This research addresses a critical gap in evidence on healthcare payment models and health outcomes in Latin America. Introduction: Understanding the impact of value-based healthcare and various healthcare payment models on the health outcomes of patients with acute myocardial infarction (AMI) is pivotal for guiding clinical strategies and decisions. Objective: To compare health outcomes and costs associated with healthcare for AMI patients under insurance prospective global payment (PGP) and fee-for-service models. Materials and Methods: A retrospective cohort study encompassing AMI patients was conducted from 2021-2023. Convenience sampling of participants over 18 years of age diagnosed with type 2 myocardial infarction was conducted. Analysis was based on Colombian healthcare system payment models: PGP and fee-for-service. Results: The study involved 2134 patients, 657 (31%) under PGP and 1477 (69%) under fee-for-service. Length of hospital stay was associated with the payment model (coefficient -0.68, CI 95%: 0.40 to 0.98, p=0.037). Payment models also correlated with costs (845 USD, CI 95%: 87.92 to 1601; p=0.02 ). In-hospital mortality is not associated with either of the two contracting models. Quality-adjusted life years (QALYs) totaled 1.6 over a 2-year follow-up. Discussion: It is evident that throughout the care cycle at the Center of Excellence for Acute Myocardial Infarction, there is added value for patients with the PGP model, as the costs are lower and health outcomes comparable to the fee-for-service model. Conclusions: The findings of this study underscore the importance of understanding the relationship between value-based healthcare, different healthcare payment models, and health outcomes in AMI patients. How to cite this article: Bermon Anderson, Licht-Ardila Maricel, Manrique-Hernández Edgar Fabián, Hurtado-Ortiz Alexandra. Analysis of health outcomes in acute myocardial infarction: A Value-Based Healthcare approach. Revista Cuidarte. 2024;15(2):e3796.  https://doi.org/10.15649/cuidarte.3796Introducción: Es fundamental comprender cómo la atención en salud basada en el valor y los diversos modelos de contratación afectan los resultados de salud de los pacientes con infarto agudo de miocardio para orientar las estrategias y decisiones clínicas. Objetivo: Comparar los resultados de salud y los costos asociados a la atención en salud de pacientes con infarto agudo de miocardio bajo los modelos de contratación de pago global prospectivo y pago por servicio.    Materiales y Métodos: Estudio de cohortes retrospectivo en pacientes con infarto agudo de miocardio realizado entre 2021 y 2023. Se realizó un muestreo por conveniencia de participantes mayores de 18 años con diagnóstico de infarto de miocardio tipo 2. El análisis se basó en dos modelos de contratación del sistema de salud colombiano: modelo de pago global prospectivo y modelo de pago por servicio. Resultados: En el estudio participaron 2134 pacientes, 657 (31%) bajo el modelo pago global prospectivo y 1477 (69%) bajo el modelo de pago por servicio. La duración de la estancia hospitalaria se asoció con el modelo de contratación (coeficiente 0,68; 95% IC: 0,04 a 1,33; p=0,037). El modelo de contratación mostró correlación con los costos (coeficiente 845; 95% IC: 87,92 a 1601; p=0,02). La mortalidad intrahospitalaria no se asocia a ninguno de los dos modelos de contratación. Los AVAC totalizaron un valor de 1,6 durante un seguimiento de 2 años. Discusión: Es evidente que en todo el ciclo de atención en el Centro de Excelencia para el Infarto Agudo de Miocardio existe un valor añadido para el paciente bajo el modelo de contratación de pago global prospectivo, ya que los costos son menores con resultados en salud comparables al modelo de contratación de pago por servicio. Conclusiones: Es crucial comprender la relación entre la atención en salud basada en el valor, los distintos modelos de contratación y los resultados de salud de pacientes con infarto agudo de miocardio. Como citar este artículo: Bermon Anderson, Licht-Ardila Maricel, Manrique-Hernández Edgar Fabián, Hurtado-Ortiz Alexandra. Analysis of health outcomes in acute myocardial infarction: A Value-Based Healthcare approach. Revista Cuidarte. 2024;15(2):e3796.  https://doi.org/10.15649/cuidarte.3796Introdução: Compreender o impacto dos cuidados de saúde baseados em valor e de vários modelos de contratação nos resultados de saúde em pacientes com enfarte agudo do miocárdio é fundamental para orientar estratégias e decisões clínicas. Objetivo: comparar os resultados de saúde e os custos associados aos cuidados de saúde para pacientes com infarto agudo do miocárdio sob modelos prospectivos de pagamento global e taxa por serviço de seguros. Materiais e Métodos: Estudo de coorte retrospectivo abrangendo pacientes com Infarto Agudo do Miocárdio, realizado de 2021 a 2023. Amostra de conveniência de participantes com 18 anos ou mais, com diagnóstico de infarto do miocárdio tipo 2. A análise baseou-se nas modalidades de contratação do sistema de saúde colombiano: modelo de pagamento global prospectivo e taxa por serviço.   Resultados: O estudo envolveu 2.134 pacientes, com 657 (31%) sob pagamento global prospectivo e 1477 (69%) sob taxa por serviço. O tempo de internação esteve associado ao modelo (Coeficiente 0,68, IC 95%: 0,04 a 1,33, p=0,037). Tipos de contratos correlacionados com custos (Coeficiente 845, IC 95%: 87,92 a 1601; p=0,02). A mortalidade intra-hospitalar não está associada a nenhum dos dois modelos de contratação. QALYs totalizaram 1,6 em um acompanhamento de 2 anos. Discussão: É evidente que ao longo de todo o ciclo de atendimento no Center of Excellence for Acute Myocardial Infarction, há valor agregado para o paciente com o Modelo de Pagamento Global Prospectivo, pois os custos são menores com resultados de saúde comparáveis à taxa por serviço tipo de contratação. Conclusões: Compreender a relação entre cuidados de saúde baseados em valor, diferentes modelos de contratação e resultados de saúde em pacientes com enfarte agudo do miocárdio é crucial. Como citar este artigo: Bermon Anderson, Licht-Ardila Maricel, Manrique-Hernández Edgar Fabián, Hurtado-Ortiz Alexandra. Analysis of health outcomes in acute myocardial infarction: A Value-Based Healthcare approach. Revista Cuidarte. 2024;15(2):e3796.  https://doi.org/10.15649/cuidarte.379

Caracterização precoce da população adulta no momento da admissão em uma seguradora como oportunidade para identificar o risco de internação

Highlights Patients’ characterization at insurers’ point of entry allows the generation of specific profiles to guide risk management programs. Predicting hospitalization risk enables timely action to minimize costs and catastrophic health events. Identifying the risks of an insurer's members is essential for managing them in a timely manner from the moment of enrollment. It is important to implement predictive programs when providing healthcare services. Introduction: Health Benefit Plan Administrators must manage the health risk of their members. Therefore, health characterization is performed from enrollment to support decision-making and timely intervention. Objective: To analyze the historical results of characterizing the adult population on admission to the insurance company in relation to the demand for all-cause and psychiatric hospitalization services. Materials and Methods: An observational cross-sectional study with members over 18 years of age, in which an analysis was made of the characterization of the adult population of the insurer and its association with the use of medical consultation services in primary care and all-cause and psychiatric hospitalizations. Bivariate and multivariate analysis was made, and odds ratios (OR) were calculated in logistic regression. Results: Variables significantly associated with having an all-cause hospitalization were identified: having referred history of heart disease OR=1.71(95%CI: 1.33; 2.20), respiratory disease OR= 1. 30(95%CI: 1.04; 1.61), chronic kidney disease OR=1.66(95%CI: 1.13; 2.45), cancer OR=1.65(95%CI: 1.14; 2.40), taking any medication permanently OR=1.35(95%CI: 1.174; 1.56) and smoking OR=1.44(95%CI: 1.12; 1.85). For psychiatric hospitalizations, a history of discouragement, depression, or little hope was relevant with OR=5.12(95%CI: 1.89; 13.87). Discussion: The characterization of patients during enrolment allowed the identification of predictor variables of hospitalization, guiding management from the primary care level minimizing costs and catastrophic health events.   Conclusion: The timely identification of specific patient profiles allows timely actions to minimize health costs and catastrophic health events. How to cite this article: Vargas-Díaz Lorena María, Pachón Arciniegas Olga Patricia, Osorio Rojas Santiago, Manrique-Hernández Edgar Fabián, Bermon Angarita Anderson. Early characterization of an adult population at an insurer’s point of entry as an opportunity to identify hospitalization risk. Revista Cuidarte. 2024;15(1):e3290.  http://dx.doi.org/10.15649/cuidarte.3290Highlights La caracterización de pacientes al ingreso de las aseguradoras permite generar perfiles específicos para la orientación de programas de gestión de riesgo. Predecir el riesgo de hospitalización permite realizar oportunamente acciones que minimizan costos y eventos catastróficos en salud. La identificación de los riesgos de los afiliados a una aseguradora es fundamental para la gestión oportuna de los mismos desde el momento de afiliación. Es importante realizar programas predictivos en la prestación de servicios de salud. Introducción: Las Entidades Administradoras de Planes de Beneficios deben gestionar el riesgo en salud de sus afiliados. Por tanto, desde la afiliación se realiza la caracterización en salud para apoyar la toma de decisiones e intervención oportuna. Objetivo: Analizar los resultados históricos de la caracterización de población adulta al ingreso de la aseguradora en relación con la demanda de servicios de hospitalización por causa general y patología psiquiátrica. Materiales y Métodos: Estudio observacional de corte trasversal con los afiliados mayores de 18 años en donde se realizó análisis de la caracterización de la población adulta y su asociación con el uso de consultas médicas en Atención Primaria y hospitalizaciones por todas las causas y por patología psiquiátrica. Se realizaron análisis bivariado y multivariado y se calcularon OR (Odds Ratio) en regresión logística. Resultados: Se identificaron variables asociadas significativamente con hospitalización por cualquier causa: haber referido antecedente de enfermedad cardiaca OR=1,71(IC95%: 1,33; 2,20), enfermedad respiratoria OR= 1,30(IC95%: 1,04; 1,61), enfermedad renal crónica OR=1,66(IC95%: 1,13; 2,45), cáncer OR=1,65(IC95%: 1,14; 2,40), tomar algún medicamento de forma permanente OR=1,35(IC95%: 1,174; 1,56) y fumar OR=1,44(IC95%: 1,12; 1,85). Para hospitalización psiquiátrica fue relevante el antecedente de desánimo, depresión o poca esperanza OR=5,12(IC95%: 1,89; 13,87). Discusión: La caracterización realizada a los pacientes en la afiliación permitió identificar variables predictoras de hospitalización orientando la gestión desde el nivel primario, minimizando costos y eventos catastróficos en salud. Conclusión: La identificación oportuna de perfiles específicos de pacientes permite realizar acciones oportunas para minimizar costos sanitarios y eventos catastróficos en salud. Como citar este artículo: Vargas-Díaz Lorena María, Pachón Arciniegas Olga Patricia, Osorio Rojas Santiago, Manrique-Hernández Edgar Fabián, Bermon Angarita Anderson. Caracterización temprana de población adulta al ingreso de una aseguradora como oportunidad para identificar el riesgo de hospitalización Revista Cuidarte. 2024;15(1):e3290.  http://dx.doi.org/10.15649/cuidarte.3290Introdução: As Entidades Administrativas de Planos de Benefícios devem gerenciar o risco à saúde de seus associados. Portanto, a partir da filiação é realizada a caracterização da saúde para apoiar a tomada de decisão e a intervenção oportuna. Objetivo: Analisar os resultados históricos da caracterização da população adulta no momento da admissão na seguradora em relação à procura por serviços de internação por causas gerais e patologia psiquiátrica. Materiais e Métodos: Estudo observacional transversal com membros maiores de 18 anos onde foi realizada análise da caracterização da população adulta e sua associação com a utilização de consultas médicas na Atenção Básica e internações por todas as causas e por patologia psiquiátrica. Foram realizadas análises bivariadas e multivariadas e calculado OR (Odds Ratio) em regressão logística.  Resultados:  Foram identificadas variáveis significativamente associadas à internação por qualquer causa: ter relatado história de doença cardíaca OR=1,71(IC95%: 1,33; 2,20), doença respiratória OR= 1,30(IC95%: 1,04; 1,61), doença renal crônica doença OR= 1,66 (IC 95%: 1,13; 2,45), câncer OR=1,65(IC 95%: 1,14; 2,40), tomar algum medicamento permanentemente OR=1,35(IC 95%: 1,174; 1,56) e fumar OR=1,44 (IC 95%: 1,12; 1,85). Para internação psiquiátrica foi relevante história de desânimo, depressão ou baixa esperança, OR=5,12 (IC 95%: 1,89; 13,87). Discussão: A caracterização realizada aos pacientes na afiliação permitiu identificar variáveis preditoras de internação, orientando o manejo desde o nível primário, minimizando custos e eventos catastróficos de saúde. Conclusão: A identificação oportuna de perfis específicos de pacientes permite que ações oportunas sejam tomadas para minimizar custos de saúde e eventos catastróficos de saúde. Como citar este artigo: Vargas-Díaz Lorena María, Pachón Arciniegas Olga Patricia, Osorio Rojas Santiago, Manrique-Hernández Edgar Fabián, Bermon Angarita Anderson. Caracterización temprana de población adulta al ingreso de una aseguradora como oportunidad para identificar el riesgo de hospitalización Revista Cuidarte. 2024;15(1):e3290.  http://dx.doi.org/10.15649/cuidarte.329

Theory of the Fano Resonance in the STM Tunneling Density of States due to a Single Kondo Impurity

The conduction electron density of states nearby single magnetic impurities, as measured recently by scanning tunneling microscopy (STM), is calculated, taking into account tunneling into conduction electron states only. The Kondo effect induces a narrow Fano resonance in the conduction electron density of states, while scattering off the d-level generates a weakly energy dependent Friedel oscillation. The line shape varies with the distance between STM tip and impurity, in qualitative agreement with experiments, but is very sensitive to details of the band structure. For a Co impurity the experimentally observed width and shift of the Kondo resonance are in accordance with those obtained from a combination of band structure and strongly correlated calculations.Comment: 4 pages, ReVTeX + 4 figures (Encapsulated Postscript), submitted to PR

Early characterization of an adult population at an insurer’s point of entry as an opportunity to identify hospitalization risk

Introduction: Health Benefit Plan Administrators must manage the health risk of their members. Therefore, health characterization is performed from enrollment to support decision-making and timely intervention. Objective: To analyze the historical results of characterizing the adult population on admission to the insurance company in relation to the demand for all-cause and psychiatric hospitalization services. Materials and Methods: An observational cross-sectional study with members over 18 years of age, in which an analysis was made of the characterization of the adult population of the insurer and its association with the use of medical consultation services in primary care and all-cause and psychiatric hospitalizations. Bivariate and multivariate analysis was made, and odds ratios (OR) were calculated in logistic regression. Results: Variables significantly associated with having an all-cause hospitalization were identified: having referred history of heart disease OR=1.71(95%CI: 1.33; 2.20), respiratory disease OR= 1. 30(95%CI: 1.04; 1.61), chronic kidney disease OR=1.66(95%CI: 1.13; 2.45), cancer OR=1.65(95%CI: 1.14; 2.40), taking any medication permanently OR=1.35(95%CI: 1.174; 1.56) and smoking OR=1.44(95%CI: 1.12; 1.85). For psychiatric hospitalizations, a history of discouragement, depression, or little hope was relevant with OR=5.12(95%CI: 1.89; 13.87). Discussion: The characterization of patients during enrolment allowed the identification of predictor variables of hospitalization, guiding management from the primary care level minimizing costs and catastrophic health events. Conclusion: The timely identification of specific patient profiles allows timely actions to minimize health costs and catastrophic health events

Evaluation of the efficacy and safety of text messages targeting adherence to cardiovascular medications in secondary prevention: the txt2heart Colombia randomised controlled trial protocol.

INTRODUCTION: Anti-platelet therapy, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta-blockers and statins are cost-effective in patients with atherosclerotic cardiovascular diseases (ASCVD) for reducing the risk of ASCVD events. Unfortunately, there is abundant evidence that adherence to these cardiovascular medications is far from ideal. A recent Cochrane review showed a potential beneficial effect of Short Message Service (SMS) interventions on adherence to medication in ASCVD patients. METHODS AND ANALYSIS: The txt2heart study is a pragmatic randomised single-blind controlled trial. The objective is to evaluate the efficacy and safety of an intervention with SMS messages delivered by mobile phones to improve adherence to cardiovascular medications in patients with ASCVD. The intervention consists of behavioural techniques delivered via SMS. The primary outcome is change in blood serum low-density lipoprotein cholesterol levels as an indicator of adherence to statins. Secondary outcomes will include systolic blood pressure as an indicator of adherence to blood-lowering therapies and heart rate as an indicator of adherence to beta-blockers, urine levels of 11-dehydrothromboxane B2, self-reported adherence to cardiovascular medications and rates of cardiovascular death or hospitalisation due to cardiovascular disease. ETHICS AND DISSEMINATION: The study will be performed in compliance with the protocol, regulatory requirements, Good Clinical Practice and ethical principles of the Declaration of Helsinki. The Ethics Committee of Fundación Cardiovascular de Colombia evaluated and approved the trial. The txt2heart Colombia trial aims to provide robust evidence to evaluate whether SMS messages delivered through mobile telephones change the behaviour of Colombian patients who have suffered a cardiovascular event. Trial results will be presented to the local health authorities, and if the intervention is effective and safe, we hope this strategy will be implemented quickly because of its low cost and wide-reaching impact on the population. TRIAL REGISTRATION NUMBER: NCT03098186

Nonequilibrium Transport through a Kondo Dot in a Magnetic Field: Perturbation Theory

Using nonequilibrium perturbation theory, we investigate the nonlinear transport through a quantum dot in the Kondo regime in the presence of a magnetic field. We calculate the leading logarithmic corrections to the local magnetization and the differential conductance, which are characteristic of the Kondo effect out of equilibrium. By solving a quantum Boltzmann equation, we determine the nonequilibrium magnetization on the dot and show that the application of both a finite bias voltage and a magnetic field induces a novel structure of logarithmic corrections not present in equilibrium. These corrections lead to more pronounced features in the conductance, and their form calls for a modification of the perturbative renormalization group.Comment: 16 pages, 7 figure

The Kondo Effect in Non-Equilibrium Quantum Dots: Perturbative Renormalization Group

While the properties of the Kondo model in equilibrium are very well understood, much less is known for Kondo systems out of equilibrium. We study the properties of a quantum dot in the Kondo regime, when a large bias voltage V and/or a large magnetic field B is applied. Using the perturbative renormalization group generalized to stationary nonequilibrium situations, we calculate renormalized couplings, keeping their important energy dependence. We show that in a magnetic field the spin occupation of the quantum dot is non-thermal, being controlled by V and B in a complex way to be calculated by solving a quantum Boltzmann equation. We find that the well-known suppression of the Kondo effect at finite V>>T_K (Kondo temperature) is caused by inelastic dephasing processes induced by the current through the dot. We calculate the corresponding decoherence rate, which serves to cut off the RG flow usually well inside the perturbative regime (with possible exceptions). As a consequence, the differential conductance, the local magnetization, the spin relaxation rates and the local spectral function may be calculated for large V,B >> T_K in a controlled way.Comment: 9 pages, invited paper for a special edition of JPSJ "Kondo Effect -- 40 Years after the Discovery", some typos correcte

Evaluating the use of laparoscopic gastrostomy in children with congenital heart disease in Colombia: a retrospective analysis

IntroductionCongenital Heart Disease (CHD) is the most common congenital disorder and a leading cause of infant mortality. Despite improved survival rates, patients with CHD often face malnutrition due to increased metabolic demands, feeding difficulties, and gastrointestinal dysfunction. Malnutrition in CHD is linked to poor short and long-term clinical outcomes. Gastrostomy (GT) is frequently used for long-term enteral support, and laparoscopic GT (LGT) has demonstrated advantages in children without CHD. This study evaluated a modified Georgeson's percutaneous LGT technique and its perioperative complications in children with CHD.MethodsWe performed an analytical retrospective cohort study from 2018 to 2022, including patients younger than 24 months with a diagnosis of CHD who underwent LGT. The primary outcome evaluated was the presence of complications during surgery and the first thirty postoperative days. Complications were graded using Clavien–Dindo's (CD) classification. Sociodemographic, clinical, and procedure-related variables were collected. A bivariate analysis was performed using STATA 15, and a p < 0.05 was considered statistically significant.ResultsSeventy-eight patients were eligible (male 56.41%, Median age 129.5 days, weight: 4.83 kg). The median surgery time was 35 min. The complication rate was 24.36%. The most frequent complications were GT site infection (10.26%), followed by leakage (8.97%) and granuloma formation (6.41%). Conversion to open surgery was significantly associated with postoperative complications (p = 0.002).ConclusionThis modified technique is well-tolerated in children with CHD, demonstrating a low rate of CD grade 3A/3B complications and no grade 4 or 5 complications

Eucapnic voluntary hyperpnea challenge can support management of exercise-induced bronchoconstriction in elite swimmers

Introduction: This study investigated the use of eucapnic voluntary hyperpnea (EVH) to monitor efficacy of pharmacological therapy in elite swimmers with exercise-induced bronchoconstriction (EIB). Secondly, it evaluated the long-term test-retest repeatability of EVH in this population. Methods: Twenty-seven elite international swimmers were included in this retrospective analysis of comprehensive respiratory assessments. Following an initial “withheld-therapy” assessment, athletes with EIB had been prescribed appropriate pharmacological therapy and returned twelve months later for a follow-up assessment to monitor EIB protection afforded by treatment. EIB-negative athletes had returned to confirm initial diagnosis, as were still reporting persistent respiratory symptoms. Athletes were retrospectively grouped into either “Therapy Adherent Group” (n = 12) or “Repeatability Group” (discontinued therapy at follow-up or EIB-negative, n = 15). Results: Greatest fall in forced expiratory volume in 1 second (ΔFEV1max) was significantly lower following therapy adherence (−11.8 ± 3.8%) compared to initial assessment (−24.0 ± 11.3%; P < .01). “Repeatability Group” ΔFEV1max did not differ significantly between initial assessment (−13.1 ± 4.5%) and follow-up (−12.3 ± 5.6%; P = .32), and showed good agreement (0.6%; −5.9%, 7.1%). Conclusion: A follow-up assessment utilizing EVH is useful in the management of EIB and shows good test-retest repeatability over twelve months in elite swimmers who discontinue treatment or are EIB-negative

Influence of a montmorency cherry juice blend on indices of exercise-induced stress and upper respiratory tract symptoms following marathon running—a pilot investigation

Background: Prolonged exercise, such as marathon running, has been associated with an increase in respiratory mucosal inflammation. The aim of this pilot study was to examine the effects of Montmorency cherry juice on markers of stress, immunity and inflammation following a Marathon. Methods: Twenty recreational Marathon runners consumed either cherry juice (CJ) or placebo (PL) before and after a Marathon race. Markers of mucosal immunity secretory immunoglobulin A (sIgA), immunoglobulin G (IgG), salivary cortisol, inflammation (CRP) and self-reported incidence and severity of upper respiratory tract symptoms (URTS) were measured before and following the race. Results: All variables except secretory IgA and IgG concentrations in saliva showed a significant time effect (P < 0.01). Serum CRP showed a significant interaction and treatment effect (P < 0.01). The CRP increase at 24 and 48 h post-Marathon was lower (P < 0.01) in the CJ group compared to PL group. Mucosal immunity and salivary cortisol showed no interaction effect or treatment effect. The incidence and severity of URTS was significantly greater than baseline at 24 h and 48 h following the race in the PL group and was also greater than the CJ group (P < 0.05). No URTS were reported in the CJ group whereas 50 % of runners in the PL group reported URTS at 24 h and 48 h post-Marathon. Conclusions: This is the first study that provides encouraging evidence of the potential role of Montmorency cherries in reducing the development of URTS post-Marathon possibly caused by exercise-induced hyperventilation trauma, and/or other infectious and non-infectious factors