El buen gobierno de la sanidad: las influencias debidas e indebidas en la formulación de políticas de salud

Los nuevos conocimientos y las experiencias adquiridas nos muestran que los retos de salud a los que se enfrentan las poblaciones actuales requieren una transformación en las políticas públicas. Constatar el efecto que en la salud de las poblaciones tienen las condiciones sociales ha determinado una mayor atención de los salubristas a la formulación de las políticas públicas. La aproximación biomédica a los problemas de salud ha motivado que la respuesta social a los problemas de salud se ciña a la provisión de servicios asistenciales cada vez más complejos y costosos. No hay duda de que debe garantizarse de atención sanitaria, pero esta no debe ir más allá de lo estrictamente imprescindible creando intervencionismo y medicalización innecesarios. Las actuaciones de prevención y promoción de la salud de carácter individual de tipo informativo se muestran insuficientes si no se acompañan de políticas que creen un entorno más saludable. Si una sociedad desean ganar salud y contribuir así a la sostenibilidad de su sistema de salud debe orientar sus políticas a las causas radicales de los problemas de salud en línea con las recomendaciones principales del informe final de la Comisión sobre Determinantes Sociales de la Salud de la Organización Mundial de la Salud que son políticas públicas en todos los niveles de gobierno. Sin embargo, la acentuación del modelo biomédico como respuesta a los problemas de salud se ha reforzado por las influencias de diversos actores interesados que a su vez han dificultado la emergencia del enfoque de salud pública y la introducción de las innovaciones sociales en las políticas de salud..

An ethics training specific for European public health

Training in public health ethics is not at the core of public health programmes in Europe. The fruitful progress of the United States could stimulate the European schools of public health and other academic institutions to develop specifically European teaching programmes for ethics that embrace both transatlantic innovations and some adaptations based on the evolution of moral values in European societies. This paper reviews the arguments for a European public health ethics curriculum and recommends the main features of such a programme. Europe shares common values and, above all, the three major ethical principles that were socially and politically crystallized by the French Revolution: liberty, equality, and fraternity. Fraternity, otherwise known as solidarity, although rarely mentioned in the literature on ethical issues, is the moral value that best defines the European concept of public health expressed as a common good, mutual aid, and a collective or shared responsibility for health of the population. Specific political motivations were responsible for the origin of European health systems and for current policy proposals led by the European Union, such as Europe's commitments, at least in theory, to: reduce social inequities in health and to develop the health in all policies approach. These and other initiatives, albeit not exclusively European, have political and legal repercussions that pose unique ethical challenges. Europe combines homogeneity in social determinants of health with heterogeneity in public health approaches and interventions. It is therefore necessary to develop training in ethics and good government for all public health workers in Europe, especially since a large segment of the population's health depends on actions and decisions adopted by the European Commission and its regulatory agencies as well as for non EU European Region countries. Based on these arguments, the paper concludes with several recommendations for a common nucleus for the ethics curriculum in Europe

Investigación en salud pública: independencia y libertad académica

Este artículo pretende contribuir al debate sobre la objetividad de la ciencia, la independencia y la libertad académica de quienes investigan. A partir de una breve panorámica sobre los factores que moldean la investigación en salud pública, se pretende iniciar una reflexión desde la perspectiva ética sobre la libertad de los y las investigadoras a la hora de realizar su investigación —las fuerzas externas e internas que la moldean— y el propósito social de su labor investigadora, que debe ser el avance del conocimiento para aumentar el bienestar social y la salud de las poblaciones

Investigación en salud pública: independencia y libertad académica

Aquest article pretén contribuir al debat sobre l'objectivitat de la ciència, la independència i la llibertat acadèmica dels qui investiguen. A partir d'una breu panoràmica sobre els factors que modelen la recerca en salut pública, es pretén iniciar una reflexió des de la perspectiva ètica sobre la llibertat dels i les investigadores a l'hora de realitzar la seva recerca —les forces externes i internes que la modelen— i el propòsit social de la seva labor investigadora, que ha de ser el progrés del coneixement a fi d’augmentar el benestar social i la salut de les poblacions.This article aims to contribute to the debate on the objectivity of science, independence and academic freedom of researchers. Based on a brief overview of the factors that shape public health research, we intend to initiate a reflection from the ethical perspective on the freedom of researchers when conducting their research —the external and internal forces that shape it— and the social purpose of their research work, which should be the advancement of knowledge to increase social welfare and the health of populations.Este artículo pretende contribuir al debate sobre la objetividad de la ciencia, la independencia y la libertad académica de quienes investigan. A partir de una breve panorámica sobre los factores que moldean la investigación en salud pública, se pretende iniciar una reflexión desde la perspectiva ética sobre la libertad de los y las investigadoras a la hora de realizar su investigación —las fuerzas externas e internas que la moldean— y el propósito social de su labor investigadora, que debe ser el avance del conocimiento para aumentar el bienestar social y la salud de las poblaciones

An ethics training specific for European public health

Training in public health ethics is not at the core of public health programmes in Europe. The fruitful progress of the United States could stimulate the European schools of public health and other academic institutions to develop specifically European teaching programmes for ethics that embrace both transatlantic innovations and some adaptations based on the evolution of moral values in European societies. This paper reviews the arguments for a European public health ethics curriculum and recommends the main features of such a programme. Europe shares common values and, above all, the three major ethical principles that were socially and politically crystallized by the French Revolution: liberty, equality, and fraternity. Fraternity, otherwise known as solidarity, although rarely mentioned in the literature on ethical issues, is the moral value that best defines the European concept of public health expressed as a common good, mutual aid, and a collective or shared responsibility for health of the population. Specific political motivations were responsible for the origin of European health systems and for current policy proposals led by the European Union, such as Europe's commitments, at least in theory, to: reduce social inequities in health and to develop the health in all policies approach. These and other initiatives, albeit not exclusively European, have political and legal repercussions that pose unique ethical challenges. Europe combines homogeneity in social determinants of health with heterogeneity in public health approaches and interventions. It is therefore necessary to develop training in ethics and good government for all public health workers in Europe, especially since a large segment of the population's health depends on actions and decisions adopted by the European Commission and its regulatory agencies as well as for non EU European Region countries. Based on these arguments, the paper concludes with several recommendations for a common nucleus for the ethics curriculum in Europe

Appropriate use of medical imaging in two Spanish public hospitals: a crosssectional analysis

Objectives To determine the appropriateness of medical imaging examinations involving radiation and to estimate the effective radiation dose and costs associated. Design Cross-sectional retrospective study. Setting Two Spanish public tertiary hospitals. Participants 2022 medical imaging tests were extracted from the radiology information system in February and March of 2014. MRI and ultrasound examinations were excluded. Primary and secondary outcome measures Five outcomes were set independently by at least two researchers according to four guidelines: (1) appropriate; (2) inappropriate; (3) inappropriate due to repetition, if the timing to carry out next diagnostic tests was incorrect according to guidelines; (4) not adequately justified, if the referral form did not include enough clinical information to allow us to understand the patient’s clinical condition; and (5) not included in the guidelines, if the referral could not be matched to a clinical scenario described in the guidelines. We estimated the prevalence of the five categories according to relevant clinical and sociodemographic variables and the effective radiation dose and costs for each category. Results Approximately half of the imaging tests were deemed as appropriate (967, 47.8%) while one-third (634, 31.4%) were considered inappropriate. 19.6% of the effective dose and 25.2% of the cost were associated with inappropriate tests. Women were less likely than men to have an imaging test classified as appropriate (adjusted OR 0.70,95% CI 0.57 to 0.86). Imaging tests requested by general practitioners were less likely to be considered appropriate than those requested by central services (adjusted OR 0.60, 95% CI 0.38 to 0.93). Mammography and CT were more likely to be appropriate than conventional X-rays. Conclusion There was a significant frequency of inappropriateness, which resulted in a high percentage of associated effective radiation dose. Percentage of inappropriateness depends on sociodemographic and clinical characteristics such as sex, age, referral physician and medical imaging test

Diagnostic Biomarkers: Are We Moving from Discovery to Clinical Application?

Despite considerable research investment, moving from biomarker discovery to clinical application has presented unique challenges. We aimed to evaluate progress toward clinical application of a sample of molecular- and “omics”-based diagnostic tests over a 10-year period. METHODS We used Scopus to locate studies, published before the December 31, 2016, citing 107 original-research articles published in 2006 that assessed the diagnostic value of a molecular- or “omics”-based test. We identified diagnostic studies of the same test and disease and determined whether the article represented progress in the validation of the molecular test. We classified the types of progress: (a) clinical validation (measuring diagnostic accuracy in a series of patients similar to the population in which the test will be used in practice), (b) technical improvement, (c) extended diagnostic application (modification of the diagnostic question attended initially by the test), (d) economic evaluation, or (e) clinical use or implementation. RESULTS In the 10-year period analyzed, 4257 articles cited the 107 diagnostic studies; 118 (2.8%) were diagnostic studies of the same test, and of these papers, 25 (21.2%) did not constitute progress toward validation of the test for use in clinical practice (potential research waste). Of the 107 molecular- or “omics”-based tests described in 2006, only 28 (26.2%) appeared to have made progress toward clinical application. Only 4 (9.1%) of 44 proteomics-based tests had made progress toward clinical application. CONCLUSIONS Articles evaluating molecular- or “omics”-based diagnostic tests are numerous in biomedical journals. Few tests have made progress toward clinical application in the 10 years following their discover

Untangling the association between prostatespecific antigen and diabetes: a systematic review and meta-analysis

Objectives Several studies have shown an inverse association between diabetes mellitus and prostate cancer (PCa). Some researchers suggest that this relationship is due to reduced PCa detection in diabetics due to lower prostate-specific antigen (PSA) levels compared to non-diabetics. Our objective is to analyze the impact of diabetes on PSA in asymptomatic men without known prostate pathology and without prior prostate intervention. Methods We searched Medline (via PubMed), Embase and Scopus. We included studies that reported the relationship between serum PSA levels and diabetes or diabetes treatment in asymptomatic adult men without known prostate pathology, and without prior prostate intervention. Pooled mean differences were compared between diabetics and non-diabetics. Results Of 2,392 screened abstracts, thirteen studies met the inclusion criteria and 8 (62%) reported appropriate measures that could be included in a meta-analysis. Eleven (85%) examined the influence of diabetes on PSA levels and 8 (62%) evaluated the influence of diabetes treatments on PSA levels. Overall diabetics had a significantly lower PSA level compared to non-diabetics (mean difference: −0.07 ng/mL; 95% CI −0.10, −0.04). Conclusions Diabetes and related factors (such as disease duration, severity and treatment) were significantly associated with lower PSA levels among asymptomatic men, yet differences were small and are unlikely to influence PCa detection in a screening setting