Inequidades socioeconómicas en la mortalidad en Colombia: tendencias, cobertura del seguro de salud y ciclos económicos

RESUMEN: El objetivo general de esta tesis es analizar las inequidades socioeconómicas en la mortalidad en Colombia y cómo su evolución se relaciona con la expansión de la cobertura de seguro de salud y con los cambios de las condiciones macroeconómicas en las últimas dos décadas. Un importante principio de organización y objetivo final de esta tesis es proporcionar una hoja de ruta de posibles políticas para reducir las inequidades en salud en Colombia. Para ello, esta tesis aborda las siguientes preguntas de investigación específicas: (1) ¿Han cambiado las inequidades por nivel socioeconómico en la mortalidad por todas las causas y por causas específicas en el período 1987-2012? (2) ¿La ampliación de la cobertura de seguro de salud contribuyó a la disminución de las tendencias en las diferencias socioeconómicas en la mortalidad en las últimas dos décadas? (3) ¿Cuál fue el impacto de las fluctuaciones macroeconómicas (ciclos económicos, medido por el PIB regional) sobre las tendencias de mortalidad en Colombia en el período 1980-2010

End-of-life practices in traumatic brain injury patients: Report of a questionnaire from the CENTER-TBI study

Purpose: We aimed to study variation regarding specific end-of-life (EoL) practices in the intensive care unit (ICU) in traumatic brain injury (TBI) patients. Materials and methods: Respondents from 67 hospitals participating in The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study completed several questionnaires on management of TBI patients. Results: In 60% of the centers, ≤50% of all patients with severe neurological damage dying in the ICU, die after withdrawal of life-sustaining measures (LSM). The decision to withhold/withdraw LSM was made following multidisciplinary consensus in every center. Legal representatives/relatives played a role in the decision-making process in 81% of the centers. In 82% of the centers, age played a role in the decision to withhold/withdraw LSM. Furthermore, palliative therapy was initiated in 79% of the centers after the decision to withdraw LSM was made. Last, withholding/withdrawing LSM was, generally, more often considered after more time had passed, in a patient with TBI, who remained in a very poor prognostic condition. Conclusion: We found variation regarding EoL practices in TBI patients. These results provide insight into variability regarding important issues pertaining to EoL practices in TBI, which can be useful to stimulate discussions on EoL practices, comparative effectiveness research, and, ultimately, development of recommendations

Work-related physical and psychosocial risk factors for sick leave in patients with neck or upper extremity complaints

Objectives: To study work-related physical and psychosocial risk factors for sick leave among patients who have visited their general practitioner for neck or upper extremity complaints. Methods: Three hundred and forty two patients with neck or upper extremity complaints completed self-report questionnaires at baseline and after 3 months. Cox regression models were used to investigate the association between work-related risk factors and sick leave (i.e., lost days from work due to neck or upper extremity complaints in 3 months). Effect modification by sick leave at baseline, sex, worrying and musculoskeletal co-morbidity was evaluated by adding product terms to the regression models. Results: In the subgroup of patients who scored high on the pain copying scale "worrying" the hazard ratio of sick leave was 1.32 (95% CI 1.07-1.62) per 10% increase in heavy physical work. The subgroup of patients who were sitting for long periods of time had a reduced risk of sick leave as compared to patients who did not spend a lot of time sitting, again only in patients who scored high on the pain coping scale "worrying" (adjusted HR = 0.17, 95%-CI 0.04-0.72). Other work-related risk factors were not significantly related to sick leave. Conclusions: Heavy physical work increased the risk of sick leave and prolonged sitting reduced the risk of sick leave in a subgroup of patients who worried much about their pain. Additional large longitudinal studies of sufficiently large size among employees with neck or upper extremity complaints are needed to confirm our results. © Springer-Verlag 2007

Methodologic issues in low back pain research in primary care

Study Design. Narrative review and discussion of the selected literature. Objectives. To discuss some important methodologic challenges in low back pain research in primary care. Summary of Background Data. Many methodologic problems must be confronted when conducting low back pain research. Some of these problems are back pain specific or specific to the primary care setting. Methods. Methodologic problems related to four research issues will be discussed: study designs, definition of low back pain, determinants of low back pain, and outcome assessment. Results. Two fundamentally different study designs are frequently used in low back pain research, namely observational studies and experimental studies. The definition of low back pain is typically restricted to a highly variable self-reported symptom, the sensation of pain in the back. There clearly is a need for an evidence-based classification system for low back pain. Because a tenable theoretical framework is lacking, it is difficult to know which determinants of low back pain should be quantified. Low back pain studies focus usually on health-related quality-of-life outcome parameters. The identification of the minimum clinically relevant changes for the most important outcome instruments needs further consideration. Conclusions. In years to come, low back pain researchers are challenged to overcome some of these (and other) problems to enhance the quality of low back pain research in primary care