Supplementary health insurance in the Colombian managed care system: Adverse or advantageous selection?

The aim of this article is to estimate the type of selection that exists in the voluntary health insurance market in Colombia where the compulsory coverage is implemented through a managed care competition. We build a panel database that combines individuals’ information from the Ministry of Health and a database provided by two private health insurers. We perform the correlation test for health expenditure and coverage. Following Fang et al. (2008), we condition the estimation on health controls that are available to the econometrician but not to insurers. In both cases we obtain a positive correlation, suggesting that adverse selection predominates. In order to rule out some moral hazard effects, we estimate the correlation between previous health service consumption and insurance purchase. The positive correlation obtained is robust to the inclusion of controls for diagnosis, suggesting that despite some risk selection strategies, health insurers are not protected from adverse selection

Voluntary Health Plan Subsidies and Public Expenditure

Countries that seek to provide universal health coverage deal with considerable publicly funded expenses. This article discusses if a private health insurance subsidy policy can reduce the expenses covered by the public system. A theoretical model is developed in which individuals are characterized by two dimensions: inherited risk of illness and preferences for prevention activities. It is shown that when beneficiaries of a voluntary plan have lower risk, i.e. advantageous selection scenario, a subsidy raises heath expenses if articulation between coverage is complementary. On the contrary, in adverse selection scenarios a subsidy reduces expenditure if articulation is supplementary. Intermediate scenarios are also considered where articulations between coverages have both complementary and supplementary components, which is apparently the case for the Colombian health system. Calibrated numerical simulations are provided using the Colombian system data. The calibration strategy employed reveals that selection is adverse in the Colombian voluntary health insurance market. Furthermore, we identify the level of subsidy and changes in articulation (towards supplementarity) that could lead to a reduction in public spending

Voluntary Health Plan Subsidies and Public Expenditure

Countries that seek to provide universal health coverage deal with considerable publicly funded expenses. This article discusses if a private health insurance subsidy policy can reduce the expenses covered by the public system. A theoretical model is developed in which individuals are characterized by two dimensions: inherited risk of illness and preferences for prevention activities. It is shown that when beneficiaries of a voluntary plan have lower risk, i.e. advantageous selection scenario, a subsidy raises heath expenses if articulation between coverage is complementary. On the contrary, in adverse selection scenarios a subsidy reduces expenditure if articulation is supplementary. Intermediate scenarios are also considered where articulations between coverages have both complementary and supplementary components, which is apparently the case for the Colombian health system. Calibrated numerical simulations are provided using the Colombian system data. The calibration strategy employed reveals that selection is adverse in the Colombian voluntary health insurance market. Furthermore, we identify the level of subsidy and changes in articulation (towards supplementarity) that could lead to a reduction in public spending

Acute kidney injury in a cohort of critical illness patients exposed to non‐steroidal anti‐inflammatory drugs

To determine whether non-steroidal anti-inflammatory drug (NSAIDs) exposure prior to intensive care unit (ICU) admission affects the development of acute kidney injury (AKI) with renal replacement therapy (RRT). An administrative database is used to establish a cohort of patients who were admitted to the ICU. The exposure to NSAIDs that the patients had before admission to the ICU is determined. Demographic variables, comorbidities, AKI diagnoses requiring RRT, and pneumonia during the ICU stay are also measured. Multivariate logistic regression and inverse probability weighting (IPW) are used to calculate risks of exposure to NSAIDs for patients with AKI requiring RRT. In total, 96,235 patients were admitted to the ICU, of which 16,068 (16.7%) were exposed to NSAIDs. The incidence of AKI with RRT was 2.71% for being exposed to NSAIDs versus 2.24% for those not exposed (p < 0.001). For the outcome of AKI, the odds ratio weighted with IPW was 1.28 (95% CI: 1.15–1.43), and for the outcome of pneumonia as a negative control, the odds ratio was 1.07 (95% CI: 0.98–1.17). The impact of prior exposure to NSAIDs over critically ill patients in the development of AKI is calculated as 8 patients per 1000 exposures. The negative control with the same sources of bias did not show an association with NSAID exposure.Q1Q1Determinar si la exposición a fármacos antiinflamatorios no esteroideos (AINE) antes del ingreso en la unidad de cuidados intensivos (UCI) afecta el desarrollo de lesión renal aguda (IRA) con terapia de reemplazo renal (TRR). Se utiliza una base de datos administrativa para establecer una cohorte de pacientes que ingresaron en la UCI. Se determina la exposición a AINE que tenían los pacientes antes del ingreso en la UCI. También se miden variables demográficas, comorbilidades, diagnósticos de FRA que requieren TRS y neumonía durante la estancia en la UCI. La regresión logística multivariante y la ponderación de probabilidad inversa (IPW) se utilizan para calcular los riesgos de exposición a los AINE para pacientes con LRA que requieren TRS. En total ingresaron en UCI 96.235 pacientes, de los cuales 16.068 (16,7%) estuvieron expuestos a AINE. La incidencia de LRA con TRS fue del 2,71% por exposición a AINE frente a 2.p < 0,001). Para el resultado de AKI, la razón de probabilidades ponderada con IPW fue de 1,28 (IC 95 %: 1,15–1,43), y para el resultado de neumonía como control negativo, la razón de probabilidades fue 1,07 (IC 95 %: 0,98–1,17). El impacto de la exposición previa a AINE en pacientes en estado crítico en el desarrollo de LRA se calcula en 8 pacientes por cada 1000 exposiciones. El control negativo con las mismas fuentes de sesgo no mostró asociación con la exposición a AINE.N/AS

Conflict violence reduction and pregnancy outcomes : a regression discontinuity design in Colombia

BACKGROUND: The relationship between exposure to conflict violence during pregnancy and the risks of miscarriage, stillbirth, and perinatal mortality has not been studied empirically using rigorous methods and appropriate data. We investigated the association between reduced exposure to conflict violence during pregnancy and the risks of adverse pregnancy outcomes in Colombia. METHODS AND FINDINGS: We adopted a regression discontinuity (RD) design using the July 20, 2015 cease-fire declared during the Colombian peace process as an exogenous discontinuous change in exposure to conflict events during pregnancy, comparing women with conception dates before and after the cease-fire date. We constructed the cohorts of all pregnant women in Colombia for each day between January 1, 2013 and December 31, 2017 using birth and death certificates. A total of 3,254,696 women were followed until the end of pregnancy. We measured conflict exposure as the total number of conflict events that occurred in the municipality where a pregnant woman lived during her pregnancy. We first assessed whether the cease-fire did induce a discontinuous fall in conflict exposure for women with conception dates after the cease-fire to then estimate the association of this reduced exposure with the risks of miscarriage, stillbirth, and perinatal mortality. We found that the July 20, 2015 cease-fire was associated with a reduction of the average number of conflict events (from 2.64 to 2.40) to which women were exposed during pregnancy in their municipalities of residence (mean differences −0.24; 95% confidence interval [CI] −0.35 to −0.13; p < 0.001). This association was greater in municipalities where Fuerzas Armadas Revolucionarias de Colombia (FARC) had a greater presence historically. The reduction in average exposure to conflict violence was, in turn, associated with a decrease of 9.53 stillbirths per 1,000 pregnancies (95% CI −16.13 to −2.93; p = 0.005) for municipalities with total number of FARC-related violent events above the 90th percentile of the distribution of FARC-related conflict events and a decrease of 7.57 stillbirths per 1,000 pregnancies (95% CI −13.14 to −2.00; p = 0.01) for municipalities with total number of FARC-related violent events above the 75th percentile of FARC-related events. For perinatal mortality, we found associated reductions of 10.69 (95% CI −18.32 to −3.05; p = 0.01) and 6.86 (95% CI −13.24 to −0.48; p = 0.04) deaths per 1,000 pregnancies for the 2 types of municipalities, respectively. We found no association with miscarriages. Formal tests support the validity of the key RD assumptions in our data, while a battery of sensitivity analyses and falsification tests confirm the robustness of our empirical results. The main limitations of the study are the retrospective nature of the information sources and the potential for conflict exposure misclassification. CONCLUSIONS: Our study offers evidence that reduced exposure to conflict violence during pregnancy is associated with important (previously unmeasured) benefits in terms of reducing the risk of stillbirth and perinatal deaths. The findings are consistent with such beneficial associations manifesting themselves mainly through reduced violence exposure during the early stages of pregnancy. Beyond the relevance of this evidence for other countries beset by chronic armed conflicts, our results suggest that the fledgling Colombian peace process may be already contributing to better population health

Prevalence of chagas disease in Colombia : a systematic review and meta-analysis

Q2Artículo de investigación1-18Background Despite the adoption of campaigns to interrupt the main vector and to detect Trypanosoma cruzi in blood banks, millions of people are still chronically infected; however, the prevalence data are limited, and the epidemiology of Chagas disease has not been systematically evaluated. This study aimed to estimate the prevalence of Chagas disease in Colombia. Methods A systematic literature review and meta-analysis was conducted to select all observational studies reporting the prevalence of Chagas disease in Colombia, based on serological diagnosis in participants of any age and published between January 2007 and November 2017. Pooled estimates and 95% confidence intervals (95% CIs) were calculated using randomeffects models. In addition, the I 2 statistic was calculated. Results The literature search yielded a total of 1,510 studies; sixteen articles with relevant prevalence data were included in the systematic review. Of these, only 12 articles were included for entry in the meta-analysis. The pooled prevalence of Chagas disease across studies was 2.0% (95% CI: 1.0–4.0). A high degree of heterogeneity was found among studies (I2 > 75%; p < 0.001). The publication bias was not statistically significant (Egger’s test, p = 0.078). The highest pooled prevalences were found in the adult population (3.0%, 95% CI: 1.0–4.0), pregnant women (3.0%, 95% CI: 3.0–4.0) and the Orinoco region (7.0%, 95% CI: 2.2–12.6). Conclusions The results indicate that the T. cruzi-infected population is aging, the adult population, pregnant women and that the Orinoco region (department of Casanare) have the highest prevalences. These results highlight the need to maintain screening and surveillance programs to identify people with chronic T. cruzi infections

Manual de práctica clínica basado en la evidencia: Controles posquirúrgicos

ResumenIntroducciónEl cuidado postanestésico disminuye las complicaciones y la mortalidad postoperatorias inmediatas relacionadas con la anestesia, acorta la estancia en las unidades de cuidado postoperatorio y mejora la satisfacción de los pacientes.ObjetivoEstablecer un conjunto de recomendaciones para el cuidado postanestésico inmediato de los pacientes que recibieron anestesia general/regional o sedación profunda/moderada en las unidades de cuidado postoperatorio.MetodologíaEs un proceso de adaptación «rápida» de guías de práctica clínica, que incluyó búsqueda sistemática. Se calificaron las guías elegibles a adaptar, mediante AGREEII. La guía seleccionada para su adaptación como manual de práctica clínica fue Practice Guidelines for Postanesthetic Care, de la American Society of Anesthesiologists. El manual fue evaluado por un grupo de anestesiólogos y epidemiólogos mediante Delphi, en términos de implementabilidad, actualización, pertinencia, consideraciones éticas y seguridad del paciente.ResultadoEl manual mantuvo las recomendaciones sobre evaluación y monitorización, manejo farmacológico de náuseas y vómito postoperatorio, antagonismo de los efectos de sedantes, analgésicos y agentes de bloqueo neuromuscular, el manejo de la emergencia y recuperación anestésica, y los criterios para egreso de la unidad. Se incluyeron indicaciones sobre condiciones y requisitos de la unidad y el ingreso del paciente a esta.ConclusionesEste manual es una guía básica sobre el manejo primario de los pacientes en la unidad de cuidado postoperatorio, y puede ser modificado o adaptado según los requerimientos institucionales y para grupos específicos de pacientes; no pretende reemplazar los protocolos existentes en cada institución ni puede definir desenlaces ni pronósticos.AbstractIntroductionPost-anesthetic care reduces the anesthesia-related postoperative complications and mortality, shortens the length of stay at the postoperative care units and improves patient satisfaction.ObjectiveTo establish a set of recommendations for immediate post-anesthetic care of patients that received general/regional anesthesia or profound/moderate sedation at the postoperative care units.MethodologyThis is a process of ‘rapid’ clinical practice guidelines adaptation, including systematic search. The illegible guidelines for adaptation were rated using AGREEII. The guideline selected to be adapted as the clinical practice handbook was Practice Guidelines for Post-anesthetic Care of the American Society of Anesthesiologists. The manual was evaluated in terms of implementation ability, up-to-date information, relevancy, ethical considerations and patient safety by the group of anesthesiologists and epidemiologists based on Delphi.ResultThe manual kept the recommendations on evaluation and monitoring, pharmacological management of postoperative nausea and vomiting, antagonistic actions for sedatives and analgesics and neuromuscular block agents, emergency management and anesthesia recovery, as well as the criteria for discharge from the unit. Indications about the conditions and requirements of the unit and patient admission were also included.ConclusionsThis handbook comprises the basic guidelines for primary management of patients at the postoperative care unit. It may be amended or adapted according to the institutional requirements and for specific patient groups and is not intended to replace the existing protocols at the particular institution and does not define outcomes or prognosis

Experimentos de elección discreta. Diseño, análisis e implementación en salud

Los experimentos de elección discreta (DCE, su sigla en inglés), son una metodología usada para evaluar preferencias de desenlaces o intervenciones relacionadas con salud. A diferencia de otras técnicas de medición que utilizan métodos simples de elección o herramientas estadísticas básicas que fallan al evaluar los beneficios específicos de una intervención, proceso de entrega, beneficio, satisfacción y preferencia de los usuarios en términos de tiempo, calidad o atributo específico, los DCE combinan, en la generación de atributos y modelamiento matemático, complejas tareas de diseño y ejecución, que mejoran la calidad y optimizan la cantidad necesaria de información mediante el uso eficiente de recursos y resultados de excelente calidad. Este documento presenta la historia, el desarrollo y la fundamentación teórica de los DCE y muestra las críticas, las potenciales limitaciones y las precauciones.Q4Discrete choice experiments (DCE) are a methodology for evaluate patient preferences for health-related outcomes or interventions. Other preference measurement techniques that use simple methods of choice or basic statistical tools that fail to evaluate the specific benefits of an intervention, delivery process, benefit, satisfaction and patients’ preferences in terms of time, quality or specific attribute. The DCE combine in the generation of attributes and mathematical modeling, complex task of designing and execution, to improve the quality and optimize the necessary amount of information, achieving an efficient use of resources with excellent quality results. This document presents globally a brief of the history, development and theoretical foundation of the DCE and then presents in a critical way the potential limitations, precautions in their use and implementation that allow to establish the possible scenarios of use and development.Revista Nacional - IndexadaS