Decolonisation and quality of care.

Delivering high quality healthcare for all requires recognising the legacies of colonialism in driving power asymmetries and producing inequitable health outcomes both within and between countries say Bernice Yanful and colleagues

Reducing medication errors for adults in hospital settings

Background: Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Medication errors in hospitalised adults may cause harm, additional costs, and even death. Objectives: To determine the effectiveness of interventions to reduce medication errors in adults in hospital settings. Search methods: We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 16 January 2020. Selection criteria: We included randomised controlled trials (RCTs) and interrupted time series (ITS) studies investigating interventions aimed at reducing medication errors in hospitalised adults, compared with usual care or other interventions. Outcome measures included adverse drug events (ADEs), potential ADEs, preventable ADEs, medication errors, mortality, morbidity, length of stay, quality of life and identified/solved discrepancies. We included any hospital setting, such as inpatient care units, outpatient care settings, and accident and emergency departments. Data collection and analysis: We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. Where necessary, we extracted and reanalysed ITS study data using piecewise linear regression, corrected for autocorrelation and seasonality, where possible. Main results: We included 65 studies: 51 RCTs and 14 ITS studies, involving 110,875 participants. About half of trials gave rise to 'some concerns' for risk of bias during the randomisation process and one-third lacked blinding of outcome assessment. Most ITS studies presented low risk of bias. Most studies came from high-income countries or high-resource settings. Medication reconciliation –the process of comparing a patient's medication orders to the medications that the patient has been taking– was the most common type of intervention studied. Electronic prescribing systems, barcoding for correct administering of medications, organisational changes, feedback on medication errors, education of professionals and improved medication dispensing systems were other interventions studied. Medication reconciliation. Low-certainty evidence suggests that medication reconciliation (MR) versus no-MR may reduce medication errors (odds ratio [OR] 0.55, 95% confidence interval (CI) 0.17 to 1.74; 3 studies; n=379). Compared to no-MR, MR probably reduces ADEs (OR 0.38, 95%CI 0.18 to 0.80; 3 studies, n=1336; moderate-certainty evidence), but has little to no effect on length of stay (mean difference (MD) -0.30 days, 95%CI -1.93 to 1.33 days; 3 studies, n=527) and quality of life (MD -1.51, 95%CI -10.04 to 7.02; 1 study, n=131). Low-certainty evidence suggests that, compared to MR by other professionals, MR by pharmacists may reduce medication errors (OR 0.21, 95%CI 0.09 to 0.48; 8 studies, n=2648) and may increase ADEs (OR 1.34, 95%CI 0.73 to 2.44; 3 studies, n=2873). Compared to MR by other professionals, MR by pharmacists may have little to no effect on length of stay (MD -0.25, 95%CI -1.05 to 0.56; 6 studies, 3983). Moderate-certainty evidence shows that this intervention probably has little to no effect on mortality during hospitalisation (risk ratio (RR) 0.99, 95%CI 0.57 to 1.7; 2 studies, n=1000), and on readmissions at one month (RR 0.93, 95%CI 0.76 to 1.14; 2 studies, n=997); and low-certainty evidence suggests that the intervention may have little to no effect on quality of life (MD 0.00, 95%CI -14.09 to 14.09; 1 study, n=724). Low-certainty evidence suggests that database-assisted MR conducted by pharmacists, versus unassisted MR conducted by pharmacists, may reduce potential ADEs (OR 0.26, 95%CI 0.10 to 0.64; 2 studies, n=3326), and may have no effect on length of stay (MD 1.00, 95%CI -0.17 to 2.17; 1 study, n=311). Low-certainty evidence suggests that MR performed by trained pharmacist technicians, versus pharmacists, may have little to no difference on length of stay (MD -0.30, 95%CI -2.12 to 1.52; 1 study, n=183). However, the CI is compatible with important beneficial and detrimental effects. Low-certainty evidence suggests that MR before admission may increase the identification of discrepancies compared with MR after admission (MD 1.27, 95%CI 0.46 to 2.08; 1 study, n=307). However, the CI is compatible with important beneficial and detrimental effects. Moderate-certainty evidence shows that multimodal interventions probably increase discrepancy resolutions compared to usual care (RR 2.14, 95%CI 1.81 to 2.53; 1 study, n=487). Computerised physician order entry (CPOE)/clinical decision support systems (CDSS). Moderate-certainty evidence shows that CPOE/CDSS probably reduce medication errors compared to paper-based systems (OR 0.74, 95%CI 0.31 to 1.79; 2 studies, n=88). Moderate-certainty evidence shows that, compared with standard CPOE/CDSS, improved CPOE/CDSS probably reduce medication errors (OR 0.85, 95%CI 0.74 to 0.97; 2 studies, n=630). Low-certainty evidence suggests that prioritised alerts provided by CPOE/CDSS may prevent ADEs compared to non-prioritised (inconsequential) alerts (MD 1.98, 95%CI 1.65 to 2.31; 1 study; participant numbers unavailable). Barcode identification of participants/medications. Low-certainty evidence suggests that barcoding may reduce medication errors (OR 0.69, 95%CI 0.59 to 0.79; 2 studies, n=50,545). Reduced working hours. Low-certainty evidence suggests that reduced working hours may reduce serious medication errors (RR 0.83, 95%CI 0.63 to 1.09; 1 study, n=634). However, the CI is compatible with important beneficial and detrimental effects. Feedback on prescribing errors. Low-certainty evidence suggests that feedback on prescribing errors may reduce medication errors (OR 0.47, 95%CI 0.33 to 0.67; 4 studies, n=384). Dispensing system. Low-certainty evidence suggests that dispensing systems in surgical wards may reduce medication errors (OR 0.61, 95%CI 0.47 to 0.79; 2 studies, n=1775). Authors' conclusions: Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies –including those that involve patients– should also be evaluated.Fil: Ciapponi, Agustín. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Fernandez Nievas, Simon E. No especifíca;Fil: Seijo, Mariana. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Inmunología, Genética y Metabolismo. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Inmunología, Genética y Metabolismo; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Rodriguez, Maria Belén. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Vietto, Valeria. Instituto Universidad Escuela de Medicina del Hospital Italiano; ArgentinaFil: García Perdomo, Herney A.. Universidad del Valle; ColombiaFil: Virgilio, Sacha. No especifíca;Fil: Fajreldines, Ana V.. Universidad Austral; ArgentinaFil: Tost, Josep. No especifíca;Fil: Rose, Christopher J.. No especifíca;Fil: Garcia Elorrio, Ezequiel. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentin

a cross-sectional international study

OBJECTIVE: To know what hospital managers and safety leaders in Ibero-American countries are doing to respond effectively to the occurrence of adverse events (AEs) with serious consequences for patients. DESIGN: Cross-sectional international study. SETTING: Public and private hospitals in Ibero-American countries (Argentina, Brazil, Chile, Colombia, Mexico, Peru, Portugal and Spain). PARTICIPANTS: A convenience sample of hospital managers and safety leaders from eight Ibero-American countries. A minimum of 25 managers/leaders from each country were surveyed. INTERVENTIONS: A selection of 37 actions for the effective management of AEs was explored. These were related to the safety culture, existence of a crisis plan, communication and transparency processes with the patients and their families, attention to second victims and institutional communication. MAIN OUTCOME MEASURE: Degree of implementation of the actions studied. RESULTS: A total of 190 managers/leaders from 126 (66.3%) public hospitals and 64 (33.7%) private hospitals participated. Reporting systems, in-depth analysis of incidents and non-punitive approaches were the most implemented interventions, while patient information and care for second victims after an AE were the least frequent interventions. CONCLUSIONS: The majority of these hospitals have not protocolized how to act after an AE. For this reason, it is urgent to develop and apply a strategic action plan to respond to this imperative safety challenge. This is the first study to identify areas of work and future research questions in Ibero-American countries.publishersversionpublishe

Access of patients with breast and lung cancer to chemotherapy treatment in public and private hospitals in the city of Buenos Aires

Objectives: Describe the time elapsed from the diagnosis to treatment with chemotherapy for patients with breast and lung cancer at public and private hospitals in Buenos Aires. Design: Retrospective cohort study. Setting: Three public and three private academic hospitals in Buenos Aires. Participants: Patients with breast (n = 168) or lung cancer (n = 100) diagnosis treated with chemotherapy. Main outcomes measures: Clinical and sociodemographic data were collected in a stratified sample. We used the Kaplan–Meier estimator to analyse the time elapsed and the log rank test to compare both groups Results: For breast cancer patients, median time elapsed between diagnosis and treatment with chemotherapy was 76 days (95% CI: 64–86) in public and 60 days (95% CI: 52–65) in private hospitals (P = 0.0001). For adjuvant and neoadjuvant treatments, median time was 130 (95% CI: 109–159) versus 64 (95% CI: 56–73) days (P < 0.0001) and 57 days (95% CI: 49–75) versus 26 (95% CI: 16–41) days, respectively (P = 0.0002). There were no significant differences in the time from first consultation to diagnosis. In patients with lung cancer, median time from diagnosis to treatment was 71 days (95% CI: 60–83) in public hospitals and 31 days (95% CI: 24–39) in private hospitals (P = 0.0002). In the metastatic setting, median time to treatment was 63 days (95% CI: 45–83) in public and 33 (95% CI: 26–44) days in private hospitals (P = 0.005). Conclusions: There are significant disparity in the access to treatment with chemotherapy for patients in Buenos Aires, Argentina.Fil: Recondo, Gonzalo. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET; ArgentinaFil: Cosacow, César. Centro de Educación Medica E Invest.clinicas; ArgentinaFil: Cutuli, Hernán Javier. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Oncología "Ángel H. Roffo"; ArgentinaFil: Cermignani, Luciano. Hospital Alemán; ArgentinaFil: Straminsky, Samanta. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Juan A. Fernández"; ArgentinaFil: Naveira, Martin. Hospital Británico de Buenos Aires; ArgentinaFil: Pitzzu, Martin. Gobierno de la Ciudad Autónoma de Buenos Aires. Hospital General de Agudos Carlos Durand; ArgentinaFil: De Ronato, Gabriela. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Juan A. Fernández"; ArgentinaFil: Nacuzzi, Gabriela. Gobierno de la Ciudad Autónoma de Buenos Aires. Hospital General de Agudos Carlos Durand; ArgentinaFil: Taetti, Gonzalo. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Oncología "Ángel H. Roffo"; ArgentinaFil: Corsico, Santiago. Hospital Británico de Buenos Aires; ArgentinaFil: Berrueta, Mabel. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Colucci, Giuliana. Centro de Educación Medica E Invest.clinicas; ArgentinaFil: Gibbons, Luz. Centro de Educación Medica E Invest.clinicas; ArgentinaFil: Gutierrez, Laura. Centro de Educación Medica E Invest.clinicas; ArgentinaFil: García Elorrio, Ezequiel. Centro de Educación Medica E Invest.clinicas; Argentin

Knowledge, beliefs and attitudes report on patient care and safety in undergraduate students: validating the modified APSQ-III questionnaire

Resumen INTRODUCCIÓN La seguridad del paciente tiene por objetivo lograr una atención en salud libre de daño. La Organización Mundial de la Salud indica que este objetivo se logra a través de la comunicación, el análisis y la prevención de eventos adversos en los pacientes. La cultura organizacional ha sido identificada como uno de los principales factores para el éxito de las intervenciones para mejorar la seguridad del paciente. Un componente esencial de la cultura en seguridad es la actitud de los profesionales de la salud hacia el error médico. Las actitudes pueden mejorarse a través de una educación apropiada en las carreras biomédicas, pero la inclusión en los programas de Argentina es escasa. El cuestionario Actitudes para la Seguridad del Paciente mide conocimientos, creencias y actitudes sobre seguridad del paciente en estudiantes de medicina de una institución en Argentina y puede resultar una herramienta útil para ser utilizada en nuestro país. OBJETIVO Validar el cuestionario modificado de Actitudes para la Seguridad del Paciente III (APSQ III, por su sigla en inglés Attitudes to Patient Safety Questionnaire III), para la medición de conocimientos, creencias y actitudes de los estudiantes de medicina del Instituto Universitario Centro de Educación Médica e Investigaciones Clínicas. Describir el nivel de conocimientos, creencias y actitudes en seguridad del paciente de los estudiantes de medicina del referido instituto en los años 2012, 2015 y 2016. MÉTODOS Diseño: estudio descriptivo. Alcance: exploratorio. Ambiente: Instituto Universitario Centro de Educación Médica e Investigaciones Clínicas en Buenos Aires, Argentina. Población: estudiantes de medicina de cuarto y quinto año. Muestreo: se estimó un tamaño de la muestra de 100 participantes para poder obtener estimaciones significativas de acuerdo al α de Cronbach >0,6. RESULTADOS La fiabilidad (consistencia interna) del instrumento, mediante α de Cronbach, mostró una correlación global de 0,695. En todas las categorías, excepto en la importancia de la seguridad del paciente en el plan de estudios y en la de inevitabilidad del error, se obtuvieron valores de α de Cronbach adecuados. Las respuestas sobre conocimientos, actitudes y percepciones sobre la seguridad del paciente en las tres cohortes de estudiantes de medicina mostró que el 57% cree entender los conceptos acerca de la seguridad del pacientes, el 53% considera que su formación los prepara para entender la causa de errores médicos, el 59% cree que los errores son inevitables y el 98% cree que un verdadero profesional no comete errores. Un 64% cree que las habilidades en esta temática sólo se adquieren a partir de la experiencia clínica. CONCLUSIÓN Este estudio muestra que el cuestionario modificado de Actitudes para la Seguridad del Paciente III es válido. Este instrumento podría ser utilizado, tanto en Argentina como en la región, para medir el impacto de la inclusión de temas relacionados con la seguridad del paciente en el currículo médico

A systematic review of population and patient perspectives and experiences as measured in Latin American and Caribbean surveys

High-quality health systems must provide accessible, people-centred care to both improve health and maintain population trust in health services. Furthermore, accurate measurement of population perspectives is vital to hold health systems accountable and to inform improvement efforts. To describe the current state of such measures in Latin America and the Caribbean (LAC), we conducted a systematic review of facility and population-based assessments that included patient-reported experience and satisfaction measures. Five databases were searched for publications on quantitative surveys assessing healthcare quality in Spanish- or Portuguese-speaking LAC countries, focusing on the domains of processes of care and quality impacts. We included articles published since 2011 with a national sampling frame or inclusion of multiple subnational regions. We tabulated and described these articles, identifying, classifying and summarizing the items used to assess healthcare quality into the domains mentioned earlier. Of the 5584 publications reviewed, 58 articles met our inclusion criteria. Most studies were cross-sectional (95%), assessed all levels of healthcare (57%) and were secondary analyses of existing surveys (86%). The articles yielded 33 unique surveys spanning 12 LAC countries; only eight of them are regularly administered surveys. The most common quality domains assessed were satisfaction (in 33 out of 58 articles, 57%), evidence-based/effective care (34%), waiting times (33%), clear communication (33%) and ease of use (31%). Items and reported ratings varied widely among instruments used, time points and geographical settings. Assessment of patient-reported quality measures through population- and facility-based surveys is present but heterogeneous in LAC countries. Satisfaction was measured frequently, although its use in accountability or informing quality improvement is limited. Measurement of healthcare quality in LAC needs to be more systematic, regular, comprehensive and to be led collaboratively by researchers, governments and policymakers to enable comparison of results across countries and to effectively inform policy implementation

Implementación de un pase estructurado de pacientes entre profesionales en una institución privada de la Ciudad Autónoma de Buenos Aires

Introduction. Failures in communication are common during patient handoffs between physicians, which predisposes to errors. Few articles have been published on this topic in Argentina. For this reason, our objective was to confirm whether using a structured handoff (I-PASS), which has been successfully used in the USA by Doctor Starmer, may reduce the omission of key data without prolonging its duration at our department. Population and methods. The study was conducted at a private facility in the Autonomous City of Buenos Aires between June 15th, 2017 and March 31st, 2018. It had a quasi-experimental, uncontrolled, before-and-after design. Pre- A nd post-intervention handoffs were assessed. The intervention included training physicians on how to use a structured handoff mnemonic (I-PASS: Illness severity, patient summary, action list, situation awareness and contingency planning, synthesis by receiver), training on team work, written computerized handoff document, feedback observations, and simulation. Results. A total of 158 and 124 pre- A nd post-intervention assessments were done respectively. The pre- A nd post-intervention comparison showed a significant improvement in most of the handoff key points. The time used for the handoff was 199 seconds (174-225) before the intervention and 210 seconds (190-230) after the intervention, p = 0.523; interruptions also decreased significantly. Conclusion. Introducing the I-PASS program reduced key data omission without prolonging handoffs. Interruptions were also reduced.Introducción. Las fallas en la comunicación son frecuentes en los pases de guardia entre médicos, lo que predispone a cometer errores. Hay escasas publicaciones en nuestro país sobre este tema. Por eso, nuestro objetivo fue corroborar si el uso de un pase estructurado (I-PASS) utilizado en EE. UU. por la Dra. Starmer, con excelentes resultados, podría reducir la omisión de datos clave sin prolongar su duración en nuestro Servicio. Población y métodos. El estudio se realizó en una institución privada de la Ciudad Autónoma de Buenos Aires desde el 15 de junio de 2017 al 31 de marzo de 2018. El diseño fue cuasiexperimental, antes-después, no controlado. Se evaluaron los pases de guardia pre- y posintervención. La intervención incluyó la capacitación de los médicos en un pase estructurado cuya regla mnemotécnica era I-PASS (importancia de la enfermedad, resumen del paciente, lista de acciones, situaciones y planes de contingencia, síntesis por el receptor), entrenamiento en trabajo en equipo, pase escrito digitalizado, observaciones con devolución y simulación. Resultados. Se realizaron 158 evaluaciones preintervención y 124 posintervención.La comparación pre- y posintervención mostró una mejoría significativa en la mayoría de los datos clave del pase de guardia. El tiempo empleado en el pase fue de 199 segundos (174- 225) preintervención y 210 segundos (190-230) posintervención, p=0,523; además, se redujeron marcadamente las interrupciones. Conclusión. La introducción del programa I-PASS redujo la omisión de datos clave sin prolongar la duración de los pases. Se lograron reducir las interrupciones.Fil: García Roig, Cristian. Sanatorio Mater Dei; ArgentinaFil: Viard, María V.. Sanatorio Mater Dei; ArgentinaFil: Garcia Elorrio, Ezequiel. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Suárez Anzorena, Inés. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Jorro Baron, Facundo Ariel. Instituto de Efectividad Clínica y Sanitaria; Argentin

Development of physical activity and food built environment quality indicators for chronic diseases in Argentina

Although obesity and non-communicable disease (NCD) prevention efforts to-date have focused mainly on individual level factors, the social and physical environments in which people live are now widely recognized as important social determinants of health. Obesogenic environments promote higher dietary energy intakes and sedentary behaviors, thus contributing to the obesity/NCD burden. To develop quality indicators (QIs) for measuring food and physical activity (PA)-built environments in municipalities. A literature review was conducted. Based on the best practices identified from this review, a draft set of candidate QI was retrieved. The initial 67 QIs were then evaluated by a modified Delphi panel of multidisciplinary health professionals (n = 40) to determine their relevance, validity, and feasibility in 3 rounds of voting and threaded discussion using a modified RAND/University of California, Los Angeles Appropriateness Methodology. Response rate for the panel was 89.4%. All final 42 QIs were rated as highly relevant, valid, and feasible (median rating ≥ 7 on a 1-9 scale), with no significant disagreement. The final QI set addresses for the PA domain: (i) promotion of PA; and (ii) improvements in the environment to strengthen the practice of PA; and for Food environment domain: (i) promotion of healthy eating; (ii) access to healthy foods; and (iii) promotion of responsible advertising. We generated a set of indicators to evaluate the PA and food built environment, which can be adapted for use in Latin American and other low- and middle-income countries.Lay Summary: The built environment has a considerable effect on health indicators such as physical activity, eating behavior, and community. There is considerable research evidence demonstrating a direct relationship between our built environments and our health. In Argentina, the Healthy Municipalities and Communities Program focuses in health promotion interventions. It was developed to seek collaboration among community members, local government authorities and other stakeholders in order to improve quality of life. However, up to date, there has not been a homogenous measure to evaluate how well a particular locality or a whole municipality supports the health and wellbeing its residents. The proposed study aims to develop a set of local valid and common measures in order to evaluate what is happening within a particular municipality. A designated group of local experts will select a set of final measures trough out an iterative multistage process in order to combine opinion into group consensus. We will ask the panel to rate, discuss and re-rate the proposed measures (based on the existing evidence). This will study provide an evaluative tool to inform policy making and program implementation, and to guide programs and initiatives aimed at combating obesogenic environments in municipalities and communities.Fil: Seijo, Mariana. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Inmunología, Genética y Metabolismo. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Inmunología, Genética y Metabolismo; ArgentinaFil: Spira, Cintia. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Chaparro, Martín. Centro Sudamericano de Excelencia para la Salud Cardiovascular; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Elorriaga, Natalia. Centro Sudamericano de Excelencia para la Salud Cardiovascular; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Rubinstein, Adolfo Luis. Centro Sudamericano de Excelencia para la Salud Cardiovascular; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: García Elorrio, Ezequiel. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Irazola, Vilma. Centro Sudamericano de Excelencia para la Salud Cardiovascular; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentin