Research Activities, November 2010: Chronic Disease: Stroke recurrence rates vary by U.S. region

Chronic Disease
Stroke recurrence rates vary by U.S. region

Recurrent ischemic stroke is a common event and a major cause of disability and death. A national study of 895,916 Medicare patients with stroke found that 9.4 percent experience another ischemic stroke necessitating rehospitalization within a year. The Southeastern, Atlantic, and Central United States all had higher rates of recurrent stroke, while lower rates were present in the Western and Northeastern regions, according to a new study. Regional variation was present for all racial/ethnic subgroups and persisted after adjustment for individual patient characteristics.

Prior to this study, regional variation for stroke mortality and stroke hospitalization rates had been demonstrated, but little was known about the geographic pattern of recurrent stroke. The researchers looked at county-level data for elderly Medicare fee-for-service beneficiaries between 2000 and 2002. Patients with recurrent stroke were more often male, younger, black, had more illnesses, higher rates of diabetes, and were more likely to have two or more hospitalizations in the prior year. However, risk factors and population demographics do not appear to account for the increased risk of recurrent stroke in the Southeast and other regions.

The reasons why high stroke incidence and recurrence are higher in certain parts of the United States remain unclear. Future research is need to determine if other factors such as genetic variation, environmental factors, health care services, and infectious disease exposure might be associated with regional patterns in stroke outcomes. This study was supported by the Agency for Healthcare Research and Quality (HS16959).

See "Geographic variation in one-year recurrent ischemic stroke rates for elderly Medicare beneficiaries in the U.S.A.," by Norrina B. Allen, Ph.D., M.P.H., Theodore R. Holford, Ph.D., Michael B. Bracken, Ph.D., and others in Neuroepidemiology 34, pp. 123-129.


Research Activities, November 2010: Chronic Disease: Stroke recurrence rates vary by U.S. region

Research Activities, November 2010: Feature Story: Plenary sessions at AHRQ annual meeting focus on connecting the dots between research and practice

Feature Story
Plenary sessions at AHRQ annual meeting focus on connecting the dots between research and practice

With interest in the Nation's health care system at an historic high, 1,823 participants from 20 countries gathered at the Agency for Healthcare Research and Quality's annual conference September 26-29 in Bethesda, Maryland, to explore how health services research can improve care for all Americans.

"We believe data can reveal new knowledge otherwise invisible to individual observation, and execution of that new knowledge can save lives and save resources," said Dr. Atul Gawande during the conference's keynote address on September 28. The surgeon, professor, New York Times bestselling author, New Yorker contributor, and AHRQ-funded researcher spoke to a packed ballroom about "Transformation and Change: Making a Complex System Safe and Right."

Dr. Gawande's speech, the conference's second plenary session, provided examples of how U.S. Army researchers harnessed trauma registry data to discover patterns in battlefield deaths.(Figure 1). Col. John Holcomb, a U.S. Army trauma surgeon, found that injuries that should have been prevented by body armor weren't, because soldiers weren't wearing it. Using research to initiate changes in troop behavior and battlefield surgery, the military has been able to reduce battlefield death rates that stubbornly remained at 25 percent since World War II to less than 10 percent today. "The key to all of this was the willingness to treat failures like scientific problems and to pursue innovations wherever that took them," said Dr. Gawande. "They're saving people who have never been saved before."

Now in its fourth year, the AHRQ conference is where "we try to connect the dots between research and practice," said Health and Human Services Secretary Kathleen Sebelius in a video address at the opening plenary session on September 27. "Translating the purity of the scientific investigation into the daily demands of a doctor's office is not an easy thing to do." Panelists at the opening plenary session agreed.

The panel, moderated by AHRQ Director, Dr. Carolyn Clancy, was convened to gather feedback from those practicing in the field on what is needed to improve 21st century health care. Dr. Maulik Joshi of the Health Research and Educational Trust, Debra Ness of the National Partnership for Women and Families, and Dr. James Mold of the University of Oklahoma Health Sciences Center "model the kind of collaboration we need to see across the country," Dr. Clancy said.(Figure 2).

Tailoring solutions at the local level

Some of the solutions for fulfilling the conference's theme of "Better Care, Better Health: Delivering on Quality for All Americans" may find purchase if they are tailored for delivery at the local level, according to the plenary speakers. For example, Dr. Mold said the family physicians he visits in rural Oklahoma could benefit from a structure similar to the U.S. Department of Agriculture's local network of extension offices, which advise local farmers on improved practices and share farming innovations. "They (physicians) need a dissemination and implementation infrastructure, something that's local but connected to each other," he said. "It's all about relationships."

Solutions must also be patient-centered, asserted Ms. Ness. Although the current health care system appears to be provider-centric, consumer preferences must be a "game-changing force" in transforming the health care system, she said. "Patients want care from somebody who knows them. They want coordinated care. More than anything else, they want their docs to talk to each other." She added that patients also want tools to help them participate as partners in their care and access to care when they need it.

Moving from identifying problems to providing solutions

Research must move beyond identifying problems to providing realistic solutions that meet both physician and consumer needs, noted Dr. Gawande. He told the audience that after "two decades chronicling the patterns and recording the symptoms and pathologies of our systems of health care delivery," it is now time to move from being "diagnosticians" to providing solutions.

Health services research has shown that solutions are within reach. For example, Dr. Gawande's AHRQ-funded research showed that when surgical team members introduce themselves and use safety checklists before and after surgery, error rates plummet. He believes research can also help local health care systems reduce overuse of inappropriate services, such as imaging and surgery, and reduce inappropriate emergency department and hospital use. Research may also provide answers for how to improve care for the terminally ill and chronically disabled, he added.

Providing solutions that will work at the local level is challenging, because communities and their needs differ widely. Using the statistic that 1 percent of patients account for 30 percent of costs, Dr. Gawande gave three examples of communities and the problems that cost them the most. The 1 percent of patients in Camden, New Jersey, suffer from severe disabilities with drug and alcohol addiction, homelessness, and poverty. Massachusetts General Hospital's 1 percent struggles with terminal illness. Finally, a self-insured company's 1 percent contends with chronic back pain and musculoskeletal injuries. Implementation of evidence-based solutions is also a challenge. Dr. Joshi remarked that hospital staff often quiz him on implementation issues. "I hear the 'how to' question all the time," he said, adding that he commends AHRQ for investing in implementation and dissemination in addition to research.

One solution for disseminating innovations may be found in AHRQ's Medicaid Medical Directors Learning Network, noted Dr. Clancy. The network provides a forum where clinical leaders of State Medicaid programs can discuss their most pressing issues. Learning network participants often use AHRQ products, such as evidence reports comparing the effectiveness of different treatments for a condition, to tackle these issues. "The idea that they have these resources at their disposal and that we could in some way hook them up with someone who could help them make sense of all these data is pretty remarkable," Dr. Clancy said.(Figure 3).

Conducting research, developing solutions, and providing answers to the "how to" falls squarely on the shoulders of those who attended the conference, concluded Dr. Gawande. "Close attention to the patterns of our failures, of our system failures, can be contentious but absolutely necessary. And we'll need to couple that with a kind of creativity to try new solutions on the smallest level, based on these patterns. That is the challenge that all of us face, and this is the room where there are the people who will do it. And this is the Agency that will help drive it. And this is the time."

Editor's Note: Webcasts of the two plenary sessions are available at http://www.ahrq.gov/about/annlconf10.htm. Session speaker presentations will be posted on the AHRQ Web site later this fall. The 2011 conference is September 18-21.


Research Activities, November 2010: Feature Story: Plenary sessions at AHRQ annual meeting focus on connecting the dots between research and practice

Research Activities, November 2010: Chronic Disease: A simple test can help assess how accurately patients report colorectal cancer screening

Chronic Disease
A simple test can help assess how accurately patients report colorectal cancer screening

Clock drawing, a simple test of cognitive skills, can help predict whether an older patient's self-report about having been screened for colorectal cancer (CRC) or being up-to-date with CRC screening is accurate, a new study reports. By identifying patients likely to have impaired thinking, the clock drawing test can help clinician-researchers avoid using inaccurate information from patients in their research. The researchers reported that 493 patients participating in the study drew a clock, completed a questionnaire about their CRC screening, and had their questionnaire responses checked via chart review.

The patients, from practices that were part of the Iowa Practice-based Research Network, were asked to draw a clock showing "10 minutes after 11" on a preprinted circle. The researchers scored the clock drawings for the remaining 493 patients on a 0–7 scale (0–3 = normal, 4–7 = abnormal). The sensitivity of self-report for ever having had a colonoscopy was 82 percent for patients who drew normal clocks and 63 percent for those drawing abnormal clocks. The specificity for self-report of being up-to-date with colonoscopy screening was 79 percent for patients who drew normal clocks and 60 percent for patients who drew abnormal clocks.

In a model that included multiple variables, only abnormal clock drawing significantly predicted higher disagreement between self-report and chart review. Income, marital status, and age were not useful predictors of such disagreement. The study was funded in part by the Agency for Healthcare Research and Quality (HS14490).

More details are in "Patient clock drawing and accuracy of self-report compared with chart review for colorectal cancer (CRC) screening," by Jeanette M. Daly, Ph.D., Barcey T. Levy, M.D., Ph.D., Mrinalini Joshi, M.D., M.P.H., and others in the May/June 2010 Archives of Gerontology and Geriatrics 50(3), pp. 341-344.

Research Activities, November 2010: Chronic Disease: A simple test can help assess how accurately patients report colorectal cancer screening

Research Activities, November 2010: Outcomes/Effectiveness Research: Pharmacy intervention for patients with limited literacy evokes positive responses from patients and pharmacists

Outcomes/Effectiveness Research
Pharmacy intervention for patients with limited literacy evokes positive responses from patients and pharmacists

Over 90 million Americans have low health literacy, meaning that they struggle to understand and act on health information, such as that provided on prescription drug labels and pharmacy information leaflets. Previous research has shown that reminder telephone calls and patient education materials, coupled with verbal counseling, may improve medication adherence. A new study shows that this type of approach is also well received by pharmacists and patients.

Researchers from Emory University's Rollins School of Public Health examined reactions to a Pharmacy Intervention for Limited Literacy (PILL) intervention that included an automated telephone reminder system, a computer-generated illustrated medication guide, and pharmacist training in clear health care communications. They gathered responses to the intervention by interviewing the 4 participating pharmacists and conducting 4 focus groups consisting of 23 predominantly poor patients from 3 outpatient pharmacies of an inner-city health system in Atlanta. Two focus groups were held 1 month after the intervention began and two focus groups were held at the conclusion of the 6-month PILL study.

Results showed the reactions by both patients and pharmacists were generally positive. Most pharmacy patients experienced few difficulties with the intervention. The illustrated medication guide, known as the PictureRx, received the most comments and was praised for its design and usefulness. The automated telephone reminder, which presented initial technological challenges, was also well-received by patients. Overall, the key elements leading to positive reactions were ease of comprehension, accessibility, and personalization to the special needs of the target population. The pharmacists were pleased with the communications skills training. Also, after some early glitches with the PictureRx, they felt it was easy to use and provided an important counseling tool for their patients. This study was partly supported by the Agency for Healthcare Research and Quality (Contract No. 290-00-0011).

See "A qualitative evaluation of a health literacy intervention to improve medication adherence for underserved pharmacy patients," by Sarah C. Blake, M.A., Karen McMorris, and Kara L. Jacobson, M.P.H., in the Journal of Health Care for the Poor and Underserved 21(2), pp. 559-567.


Research Activities, November 2010: Outcomes/Effectiveness Research: Pharmacy intervention for patients with limited literacy evokes positive responses from patients and pharmacists

Research Activities, November 2010: Outcomes/Effectiveness Research: Pharmacy intervention for patients with limited literacy evokes positive responses from patients and pharmacists

Outcomes/Effectiveness Research
Pharmacy intervention for patients with limited literacy evokes positive responses from patients and pharmacists

Over 90 million Americans have low health literacy, meaning that they struggle to understand and act on health information, such as that provided on prescription drug labels and pharmacy information leaflets. Previous research has shown that reminder telephone calls and patient education materials, coupled with verbal counseling, may improve medication adherence. A new study shows that this type of approach is also well received by pharmacists and patients.

Researchers from Emory University's Rollins School of Public Health examined reactions to a Pharmacy Intervention for Limited Literacy (PILL) intervention that included an automated telephone reminder system, a computer-generated illustrated medication guide, and pharmacist training in clear health care communications. They gathered responses to the intervention by interviewing the 4 participating pharmacists and conducting 4 focus groups consisting of 23 predominantly poor patients from 3 outpatient pharmacies of an inner-city health system in Atlanta. Two focus groups were held 1 month after the intervention began and two focus groups were held at the conclusion of the 6-month PILL study.

Results showed the reactions by both patients and pharmacists were generally positive. Most pharmacy patients experienced few difficulties with the intervention. The illustrated medication guide, known as the PictureRx, received the most comments and was praised for its design and usefulness. The automated telephone reminder, which presented initial technological challenges, was also well-received by patients. Overall, the key elements leading to positive reactions were ease of comprehension, accessibility, and personalization to the special needs of the target population. The pharmacists were pleased with the communications skills training. Also, after some early glitches with the PictureRx, they felt it was easy to use and provided an important counseling tool for their patients. This study was partly supported by the Agency for Healthcare Research and Quality (Contract No. 290-00-0011).

See "A qualitative evaluation of a health literacy intervention to improve medication adherence for underserved pharmacy patients," by Sarah C. Blake, M.A., Karen McMorris, and Kara L. Jacobson, M.P.H., in the Journal of Health Care for the Poor and Underserved 21(2), pp. 559-567.


Research Activities, November 2010: Outcomes/Effectiveness Research: Pharmacy intervention for patients with limited literacy evokes positive responses from patients and pharmacists

Research Activities, November 2010: Outcomes/Effectiveness Research: Colonoscopy is best at diagnosing lower intestinal bleeding

Outcomes/Effectiveness Research
Colonoscopy is best at diagnosing lower intestinal bleeding

When it comes to lower intestinal bleeding (LIB), identifying the source is critical for effective diagnosis and treatment. This can be difficult, particularly at the time a patient presents with the problem. There are a number of currently available radiological procedures available to diagnose and manage LIB. Despite these newer strategies, a recent review of studies on the topic supports the use of colonoscopy as the preferred approach in most patients with LIB.

According to the researchers, colonoscopy provides clear advantages over other radiological procedures. Not only can it provide a diagnosis, but it can also provide an opportunity to stop the bleeding. According to the literature, colonoscopy can diagnose LIB in 75 to 100 percent of patients. Other radiographic tests require active bleeding at the time of the procedure. As such, colonoscopy has a higher diagnostic yield compared with these other tests. In patients with severe bleeding, it is advantageous to perform colonoscopy as soon as possible after a patient presents with LIB, preferably within 12 hours. Urgent colonoscopy can also identify low-risk patients who may be candidates for early discharge. In fact, the time to colonoscopy strongly predicts the length of stay for the patient.

Angiography and other radiologic strategies are best reserved for patients with significant bleeding who cannot be stabilized for a colonoscopy and for patients with obscure bleeding sources. They are not designed for routine cases in that they require active bleeding at the time they are performed. When angiography is used, elderly patients and those with coexisting illnesses may have serious complications. The researchers conclude that colonoscopy remains the preferred strategy for most patients, owing to its high diagnostic yield, low complication rate, and the ability to identify and treat the source of bleeding immediately. The study was supported in part by the Agency for Healthcare Research and Quality (HS14062).

See "The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding," by Lisa L. Strate, M.D., and Christopher R. Naumann, M.D., in Clinical Gastroenterology and Hepatology 8, pp. 333-343, 2010.

Research Activities, November 2010: Outcomes/Effectiveness Research: Colonoscopy is best at diagnosing lower intestinal bleeding

Research Activities, November 2010: Announcements: AHRQ releases new and improved Registries for Evaluating Patient Outcomes

Announcements
AHRQ releases new and improved Registries for Evaluating Patient Outcomes

The Agency for Healthcare Research and Quality (AHRQ) Effective Health Care program released the second edition of Registries for Evaluating Patient Outcomes: A User's Guide available at http://www.effectivehealthcare.ahrq.gov. Originally published in 2007, the handbook has been completely updated with four new sections addressing emerging topics in registry science:

•"When to Stop a Registry."
•"Linking Registry Data."
•"Technical and Legal Considerations."
•"Interfacing Registries and Electronic Health Records."

Important updates to existing chapters include: "Principles of Registry Ethics, Data Ownership, and Privacy," which now addresses recent developments affecting the privacy rule and discusses new laws including the HITECH Act and the Genetic Nondiscrimination Act. The updated guide contains 38 case studies examining real challenges in the development, use, and analysis of registries. To order printed copies of the handbook, call 1-800-358-9295.

To learn more about the AHRQ Effective Health Care Program, visit http://www.effectivehealthcare.ahrq.gov.

Research Activities, November 2010: Announcements: AHRQ releases new and improved Registries for Evaluating Patient Outcomes

Research Activities, November 2010: Announcements: AHRQ releases new Spanish language guides on women's health, cholesterol treatment, and other topics

Announcements
AHRQ releases new Spanish language guides on women's health, cholesterol treatment, and other topics

The Agency for Healthcare Research and Quality (AHRQ) recently released a series of free evidence-based guides designed to help Spanish speakers understand and compare the risks, benefits, and side effects of treatments for eight health conditions.

The guides provide valuable information that patients can use in talking with their clinicians. Half of the topics cover health issues specifically for women, including guides on controlling gestational diabetes during pregnancy, deciding to induce labor, and comparing core needle biopsy to surgical biopsy for breast lesions. Other guides cover treatments for high cholesterol, osteoarthritis of the knee, and the use of insulin analogues for treating type 2 diabetes.

"Many Spanish speakers don't have access to credible, easy-to-understand information about health care conditions and their treatment options, and that can be a significant barrier to seeking medical care," said Carolyn M. Clancy, M.D., AHRQ director. "These guides represent important resources that will help encourage patients to seek care and work with their doctors to discuss all of their treatment options."

Dr. Clancy added that AHRQ's 2009 National Healthcare Disparities Report shows that while the quality of health care is slowly improving for the nation as a whole, for many measures the report tracks, it is getting worse for Hispanics.

The new publications are part of AHRQ's growing inventory of plain-language, English and Spanish guides that summarize the scientific evidence on various health conditions so that consumers can learn more about the effectiveness and risk of different treatment options. The guides are produced by AHRQ's Effective Health Care Program, a leading Federal effort to conduct comparative effectiveness research. That program, authorized by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, represents an important Federal effort to compare treatments for health conditions and make the findings public. The program is intended to help patients, doctors, nurses, pharmacists, and others choose the most effective treatments for individual patients.

The titles of the eight guides are:

•Insulina premezclada para la diabetes tipo 2. Guía para adultos (Premixed Insulin for Type 2 Diabetes: A Guide for Adults).
•Tratamientos para el cholesterol alto. Guía para adultos (Treating High Cholesterol: A Guide for Adults).
•Osteoartritis de la rodilla. Guía para adultos (Osteoarthritis of the Knee: A Guide for Adults).
•Diabetes gestacional. Guía para la mujer embarazada (Gestational Diabetes: A Guide for Pregnant Women).
•Cuando se tiene una biopsia del seno. Guía para las mujeres y sus familias (Having a Breast Biopsy: A Guide for Women and Their Families).
•Ablación con radiofrecuencia para tartar la fibrilación auricular. Guía para adultos (Radiofrequency Ablation for Atrial Fibrillation: A Guide for Adults).
•Reduzca el riesgo de cáncer del seno con medicamentos. Guía para la mujer (Reducing the Risk of Breast Cancer with Medicine: A Guide for Women); and
•¿Está pensando que le induzcan el parto? Guía para la mujer embarazada (Thinking about Having Your Labor Induced? A Guide for Pregnant Women).

In addition to the new guides, AHRQ previously released Spanish-language guides on nine other topics, including oral medicines for type 2 diabetes, pain medicines for osteoarthritis, medications for adults with depression, and treatments for osteoporosis and prostate cancer. To access all of AHRQ's Spanish-language comparative effectiveness guides for patients and consumers, go to http://effectivehealthcare.ahrq.gov/index.cfm/informacion-en-espanol or call AHRQ's Publications Clearinghouse at (800) 358-9295.

For AHRQ's entire inventory of free Spanish-language consumer health information products, go to http://www.ahrq.gov/consumer/espanoix.htm.

Research Activities, November 2010: Announcements: AHRQ releases new Spanish language guides on women's health, cholesterol treatment, and other topics

Research Activities, November 2010: HIV/AIDS Research: Internet-based personal health records helpful to most HIV/AIDS patients who used them

HIV/AIDS Research
Internet-based personal health records helpful to most HIV/AIDS patients who used them

Public health records (PHRs) are a free, secure, Internet-based application that allows patients to retrieve comprehensive information such as laboratory test results and to share their health information with providers. Clinicians may use the application to document and verify demographics, diagnoses, medications, and laboratory data. A new study shows that the majority of HIV/AIDS patients who used the PHR at a San Francisco General Hospital HIV/AIDS clinic found it helped them manage their disease.

The researchers activated a session tracking tool in order to measure online PHR use and added a 25-item evaluation survey to the PHR. Session usage was tracked for 136 persons, with the median number of sessions being 7 and the median session length being 4 minutes. Thirty-eight percent of this group completed the 25-item survey. Of these, more than 80 percent agreed that the PHR helped them manage their medical problems, prepared them better for their visits, and helped them take charge of their health care.

The most popular page contained laboratory values, lists of medical conditions, medication lists, and links to information about health conditions. The finding that nearly a third of patients did not agree that the information in their PHR was confidential was surprising. It is not clear whether this concern impacted patients' PHR use. The PHR, known as "myHERO," was made available at the HIV/AIDS clinic between March 2007 and December 2008. In this period, 221 of 3,760 patients registered for their online PHR account. Compared with the entire clinic, these initial users were more likely to be white, male, non-Hispanic, on antiretroviral medications, and have better control of their HIV infection.

The researchers believe that this project demonstrated that HIV/AIDS patients receiving care in a safety-net setting will choose to create, activate, and use a PHR. The study was supported in part by the Agency for Healthcare Research and Quality (HS17787).

See "Personal health records in a public hospital: Experience at the HIV/AIDS clinic at San Francisco General Hospital," by James S. Kahn, M.D. Joan F. Hilton M.D., T. Van Nunnery, and others in the Journal of the American Medical Informatics Association 17, pp. 224-228, 2010.

Research Activities, November 2010: HIV/AIDS Research: Internet-based personal health records helpful to most HIV/AIDS patients who used them

Research Activities, November 2010: Women's Health: 9/11 attacks may have caused miscarriages of male fetuses

Women's Health
9/11 attacks may have caused miscarriages of male fetuses

The odds of having a male baby tend to fall after a natural or social disaster, research has shown. The communal bereavement hypothesis may be one explanation for this drop. It asserts that the widespread distress that occurs after a disaster can also affect individuals, like pregnant women, who have never met the victims of the disaster. For pregnant women, this stress can lead to production of corticosteroids that adversely affect male more than female fetuses, suggests a new study.

Researchers from the University of California at Irvine found that the events of September 11, 2001, led to a rise in miscarriages of male fetuses. Using 1996 to 2002 fetal death data files from the National Vital Statistics System, which records fetal deaths at 20 weeks or more, and birth certificate data from the National Vital Statistics System, the authors found that the odds of male fetal death increased unexpectedly in the United States (except for California) in September 2001. Further, the ratio of males expected to be born in December 2001 fell below expected values.

These findings suggest that the physiological response pregnant women experience after tragedies can threaten the gestation of male fetuses and serve as an indicator of how pregnant women react to societal stressors, the authors state. This study was funded in part by the Agency for Healthcare Research and Quality (T32 HS00086).

See "Male fetal loss in the U.S. following the terrorist attacks of September 11, 2001," by Tim A. Bruckner, Ph.D., Ralph Catalano, Ph.D., M.R.P., and Jennifer Ahern, Ph.D., M.P.H., in the May 25, 2010 BMC Public Health 10, pp. 273.

Research Activities, November 2010: Women's Health: 9/11 attacks may have caused miscarriages of male fetuses

Research Activities, November 2010: Outcomes/Effectiveness Research: Hospital report cards on coronary bypass surgery are more accurate when based on 2-year data

Outcomes/Effectiveness Research
Hospital report cards on coronary bypass surgery are more accurate when based on 2-year data

The public reporting of hospital outcomes data is becoming increasing popular, particularly with the availability of the Internet. Patients and their doctors can now find information on how hospitals do when it comes to various conditions and treatments. One area where these "mortality report cards" have become popular is for coronary artery bypass graft (CABG) surgery. However, these data may not be accurate for predicting subsequent hospital performance depending on how old the data are. A new study finds that patients and doctors can rely on risk-adjusted outcomes reports based on 2-year-old data for CABG surgery as a strong predictor of future hospital performance. However, mortality report cards based on 3-year-old data are not that useful when it comes to identifying low-performance hospitals.

Researchers looked at hospital mortality measures at 37 hospitals in New York State that perform CABG surgery. Patients and doctors can access such data from the State's health department Web site. At the moment, CABG mortality report cards are based either on 2- or 3-year old data. An observed-to-expected mortality rate (O-to-E ratio) was used to determine the association between a hospital's past quality ranking and its future performance. The subsequent performance of hospitals classified as low-performance in their 3-year-old report cards was no different than that of hospitals classified as average hospitals. Hospitals identified as high-quality using 3-year-old data had a subsequent O-to-E ratio that was 19.4 percent lower than intermediate-quality hospitals. At the same time, hospitals identified as low-quality hospitals based on 3-year-old data had subsequent O-to-E ratios nearly identical to intermediate-quality hospitals. On the other hand, high-quality hospitals identified by using 2-year-old data had O-to-E ratios that were 16.8 percent lower than intermediate-quality hospitals. Also, there was a 31.8 percent higher O-to-E ratio for low-quality hospitals compared with intermediate-quality hospitals.

Based on these findings, the researchers recommend that New York State base its CABG surgery mortality rates on 2-year-old data. The study was supported in part by the Agency for Healthcare Research and Quality (HS16737).

See "How well do hospital mortality rates reported in the New York State CABG report card predict subsequent hospital performance?" by Laurent G. Glance, M.D., Andrew W. Dick, Ph.D., Dana B. Mukamel, Ph.D., and others in the May 2010 Medical Care 48(5), pp. 466-471.

Research Activities, November 2010: Outcomes/Effectiveness Research: Hospital report cards on coronary bypass surgery are more accurate when based on 2-year data

Research Activities, November 2010: Safety and Quality of Care: Cesarean delivery rates may not be a useful measure of obstetric quality

Safety and Quality of Care
Cesarean delivery rates may not be a useful measure of obstetric quality

There are currently no uniformly accepted measures of obstetrical quality. The risk-adjusted cesarean delivery rate historically has been a proposed quality measure. Earlier studies have suggested that both higher-than-expected and lower-than-expected rates may be associated with adverse maternal and neonatal outcomes. However, a new study suggests that risk-adjusted cesarean delivery rates may not be a useful measure of obstetric quality.

The researchers correlated risk-adjusted cesarean delivery rates with important maternal and neonatal outcomes in a study of 845,000 women from 401 hospitals in California and Pennsylvania. Their study found that 60 percent of 107 hospitals with lower-than-expected risk-adjusted cesarean delivery rates had a higher-than-expected rate of at least one of six adverse outcomes. This compared with 36.1 percent of the as-expected group and 19.6 percent of hospitals with higher-than-expected risk-adjusted cesarean delivery rates. On the other hand, hospitals with higher-than-expected cesarean delivery rates had similar rates of adverse outcomes as the as-expected hospitals on the other six delivery outcome measures.

The researchers stress that the lack of a correlation between a higher-than-expected cesarean delivery rate and adverse outcomes should not suggest that a higher-than-expected rate is desirable. Instead, it likely reflects an overuse of medical care and the performance of unnecessary procedures. What's more, the higher rate of c-sections did not result in improved outcomes. The study evaluated all the women from the hospitals and a smaller subset of women delivering single babies for the first time with no history of prior cesarean delivery. The results for the smaller group were similar to those of the larger group.

The outcome measures were a composite maternal outcome measure, a composite neonatal outcome measure, and four patient safety indicators from the Agency for Healthcare Research and Quality (AHRQ): birth trauma, injury with instrumented vaginal delivery, injury with noninstrumented vaginal delivery, and injury with cesarean delivery. This study was supported in part by the Agency for Healthcare Research and Quality (HS15696).

See "Evaluating risk-adjusted cesarean delivery rate as a measure of obstetric quality," by Sindhu K. Srinivas, M.D., Corinne Fager, M.S., and Scott A. Lorch, M.D. in the May 2010 Obstetrics and Gynecology 115(5), pp. 1007-1013.

Research Activities, November 2010: Safety and Quality of Care: Cesarean delivery rates may not be a useful measure of obstetric quality

Research Activities, November 2010: Safety and Quality of Care: AHRQ patient safety indicator can be used to identify cases of hospital-acquired collapsed lung

Safety and Quality of Care
AHRQ patient safety indicator can be used to identify cases of hospital-acquired collapsed lung

Pneumothorax (collapsed lung) is a relatively frequent and potentially serious complication of hospital procedures performed near the lung. The complication is most commonly associated with central vein catheter (CVC) placement, nasogastric tube insertion, and other procedures involving the neck or chest wall that introduce air into the space between the pleural membrane and the lung. Symptoms include sudden chest pains, shortness of breath, and rapid heart beat. A new study shows that the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI) 6, Iatrogenic (hospital-acquired) Pneumothorax, can identify this complication from administrative data. It also suggests that many of these complications could have been prevented with use of real-time ultrasound guidance when performing CVC insertion and other procedures.

AHRQ has developed PSIs of potentially preventable complications using readily available administrative data. The indicators are based on diagnostic codes and have become a widely used tool to assess, monitor, and compare safety-related aspects of hospital performance. The study found that PSI 6 software, used to analyze hospital administrative data for 200 randomly selected cases of suspected pneumothorax from 28 hospitals, correctly identified 78 percent of cases that were confirmed on the basis of chart-abstracted data. CVC placement was found to be associated with 44 percent of the pneumothorax events (59 events). However, only five of these procedures used ultrasound guidance, which is known to reduce the risk of pneumothorax by more than half.

The findings were based on a retrospective study of a cross-section of records that met criteria for PSI 6 from a voluntary group of 47 hospitals in 29 States. However, only 28 of the hospitals had pneumothorax cases involving a hospital discharge between October 2005 and March 2007. The study was funded in part by the Agency for Healthcare Research and Quality (Contract No. 290-04-0020).

More details are in "Cases of iatrogenic pneumothorax can be identified from ICD-9-CM coded data," by Banafsheh Sadeghi, M.D., Ph.D., Ruth Baron, R.N., Patricia Zrelak, Ph.D., and others in the March 2010 American Journal of Medical Quality 25(3), pp. 218-224.

Research Activities, November 2010: Safety and Quality of Care: AHRQ patient safety indicator can be used to identify cases of hospital-acquired collapsed lung

Research Activities, November 2010: Safety and Quality of Care: Various factors affect providers' ability to identify spoken drug names

Safety and Quality of Care
Various factors affect providers' ability to identify spoken drug names

A number of drugs have similar sounding names. This can create confusion among health care providers, particularly when using the telephone for medication orders. In a new study, researchers found several factors that can affect how a provider hears, understands, and identifies drug names. These include voice signal-to-background noise ratios, familiarity with the drug name, prescribing frequency, and the similarity of drug names.

A total of 62 pharmacists, 74 family physicians, and 70 nurses were recruited for this study from annual meetings held during 2005. In addition, 43 nonmedical consumers from the general public also participated. The researchers selected 99 brand and 99 generic drug names to be used in the study. These names were then recorded using correct, clinical pronunciation. Participants sat at a computer with headphones. They were asked to repeat back the name of the drug they had heard. These were presented against a background of multitalker noise at three different signal-to-noise conditions. The responses were recorded. In a second step, they went to a different computer where they read aloud all of the drug names from words presented on the screen. They were also asked to rate how familiar they were with each drug name.

The ability of providers to accurately identify spoken drug names increased significantly as the signal-to-noise ratio increased (i.e., as the noise decreased). A provider's subjective familiarity with a name also increased their accuracy in identifying the correct drug name. If a drug was frequently prescribed at the national level, participants were more often able to identify it. In the case of clinicians but not lay people, the existence of similar sounding drug names decreased their ability to accurately identify a particular target drug name.

The researchers recommend that providers receiving telephone orders have the ability to increase the voice signal volume to minimize errors. Using noise-cancelling headphones or being in a quiet area can also help. Other strategies, such as reading back the name, spelling it out, and using both brand and generic names can assist in reducing confusion over spoken drug names. The study was supported in part by the Agency for Healthcare Research and Quality (HS11609).

See "Listen carefully: The risk of error in spoken medication orders," by Bruce L. Lambert, Ph.D., Laura Walsh Dickey, Ph.D., William M. Fisher, Ph.D., and others in the 2010 Social Science & Medicine 79, pp. 1599-1608.

Research Activities, November 2010: Safety and Quality of Care: Various factors affect providers' ability to identify spoken drug names

Research Activities, November 2010: Safety and Quality of Care: Electronic medical record boosts documentation of test results, but still falls short for patient notification and test followup

Safety and Quality of Care
Electronic medical record boosts documentation of test results, but still falls short for patient notification and test followup

The electronic medical record (EMR) can do a great deal to improve office-based care, including reducing medical errors. However, while physicians believe that the EMR will greatly impact test result procedures, this is not always the case. A recent study found that while the EMR does increase the documentation of patient test results, it still falls short when it comes to notifying patients, documenting the interpretation of results, and following up on abnormal test results.

Researchers examined patient charts from eight primary care offices in Ohio. They reviewed a total of 461 test results in 200 charts. Of these, 274 were managed by EMR at 4 offices, with the others managed by standard paper-based procedures. There were significant differences between EMR vs. paper charts in the way test results were documented. Both did well at ensuring that the results were in the proper location in the chart. However, while 86 percent of paper test results had a clinician signature, all of the EMR results did. Also the EMR was better at documentation of test result interpretation and patient notifications. However, the success rate declined greatly for both EMR and paper charting when it came to writing a results interpretation in the chart and documenting patient notification. There were also low rates of documentation regarding needed followup of abnormal test results for both the EMR and paper systems.

The researchers concluded that the EMR is not being used to its fullest potential when it comes to steps involving the active input of staff and clinicians. They note that an important unresolved issue is whether an EMR really increases test result management quality or just documentation. The study was supported in part by the Agency for Healthcare Research and Quality (HS13914).

See "The management of test results in primary care: Does an electronic medical record make a difference?" by Nancy C. Elder, M.D., M.S.P.H., Timothy R. McEwen, M.S., John Flach, Ph.D., and others in the May 2010 Family Medicine 42(5), pp. 327-333.

Research Activities, November 2010: Safety and Quality of Care: Electronic medical record boosts documentation of test results, but still falls short for patient notification and test followup

Research Activities, November 2010: Safety and Quality of Care: MRSA can spread slowly but surely in households

Safety and Quality of Care
MRSA can spread slowly but surely in households

Methicillin-resistant Staphylococcus aureus (MRSA) was once a bacterium found only in health care settings, but more often is now being found in communities. In households, the bacteria can spread from family member to family member through casual contact.

Researchers at the University of Pennsylvania School of Medicine identified eight individuals with MRSA infections and asked all family members of these patients to swab their noses, armpits, throats, groins, and perineum every 2 weeks for 3 months and send the samples to a laboratory to be tested for MRSA colonies. Among the eight MRSA-infected patients, it took an average of 33 days to clear MRSA colonization. Among the seven family members, three (43 percent) were also colonized with MRSA. One was found to be positive for MRSA colonies at the first test; two others became colonized after they were enrolled in the study. Among these three patients, it took an average of 54 days for MRSA to clear. Having a MRSA-colonized family member was associated with a longer duration of MRSA colonization in the individual with the original MRSA infection.

These results suggest the colonization for community-acquired MRSA occurs within households. Further, when a second family member becomes colonized with MRSA, the duration of MRSA colonization increases for the patient who originally brought the MRSA into the home. This study was funded in part by the Agency for Healthcare Research and Quality (H16946).

See "The impact of household transmission on duration of outpatient colonization with methicillin-resistant Staphylococcus aureus," by Ebbing Lautenbach, M.D., M.P.H., M.S.C.E., Pam Tolomeo, M.P.H., C.C.R.P., Irving Nachamkin, Dr.P.H., M.P.H., and others in the May 2010 Epidemiology and Infection 138(5), pp. 683-685.

Research Activities, November 2010: Safety and Quality of Care: MRSA can spread slowly but surely in households

Research Activities, November 2010: Safety and Quality of Care: Whistleblowers in pharmaceutical fraud cases pursue Federal lawsuits for moral reasons, not money

Safety and Quality of Care
Whistleblowers in pharmaceutical fraud cases pursue Federal lawsuits for moral reasons, not money

Whistleblowers who help the U.S. Department of Justice (DOJ) identify and win health care fraud cases can reap large financial awards. However, a new study finds that money is not a motivator for the individuals who launch these lawsuits. Instead, integrity, altruism, public safety, justice, and self-preservation prompt them to file lawsuits under the Federal False Claims Act.

Aaron S. Kesselheim, M.D., J.D., M.P.H., of Brigham and Women's Hospital and Harvard Medical School, and his colleagues identified all individuals who had filed lawsuits leading to settlements against pharmaceutical companies under the Federal False Claims Act from 2001 to March 2009. These "qui tam" actions let individuals who have direct knowledge of a fraud initiate a lawsuit on the government's behalf. If the DOJ pursues the claim, the whistle-blower can receive between 15 and 25 percent of the judgment. The researchers found 42 unique whistleblowers, and 26 agreed to participate in semi-structured long-form interviews (62 percent). Among the sample, 5 received awards under $1 million, 13 received between $1 and $5 million, and 7 received more than $5 million (1 chose not to disclose the amount).

None of the respondents cited money as a reason for going forward with a lawsuit. In fact, the most common reason, cited by 11 whistleblowers, was integrity. According to the authors, these individuals described strong personal ethical standards that inspired the whistleblowers to come forward with evidence of wrongdoing. More than 80 percent of the whistleblowers described some form of retribution related to their behaviors. Five reported loss of employment, five reported being blackballed from subsequent jobs in the pharmaceutical industry, and five reported some form of direct intimidation, including possibly being implicated in the wrongdoing. Whistleblowers also felt that their involvement in the qui tam lawsuits led to financial turmoil, personal stress, and health problems, and some whistleblowers reported conflicts with DOJ personnel about the speed of the process or the ability of DOJ investigators to share information about the stage of the investigation.

The authors suggest that the toll these lawsuits take on their filers may limit the effectiveness of the False Claims Act in combating health care fraud, for example, by making prospective whistleblowers reluctant to come forward. Greater recognition by the government of the hardship associated with this process, such as offering whistleblowers temporary financial help or medical benefits, could help promote responsible whistle-blowing. Additionally, because financial awards were not always proportionate to the whistleblowers' contribution in the case (e.g., those who work inside a company were likely to bring the most relevant evidence to light and were also more likely to experience professional or personal stress), the DOJ should develop better approaches to equitable distribution of the whistleblower portion of the settlement. This study was funded in part by the Agency for Healthcare Research and Quality (HS18465).

See "Whistle-blowers' experiences in fraud litigation against pharmaceutical companies," by Dr. Kesselheim, David M. Studdert, LL.B., Sc.D., M.P.H., and Michelle M. Mello, J.D., Ph.D., M.Phil., in the May 13, 2010, New England Journal of Medicine 362(19), pp. 1832-1839.

Research Activities, November 2010: Safety and Quality of Care: Whistleblowers in pharmaceutical fraud cases pursue Federal lawsuits for moral reasons, not money

Research Activities, November 2010: Safety and Quality of Care: Oral chemotherapy drugs not immune to medication errors

Safety and Quality of Care
Oral chemotherapy drugs not immune to medication errors

Oral chemotherapy drugs are as susceptible to medication errors as other prescription medications, a new study finds. Saul N. Weingart, M.D., Ph.D., of the Dana-Farber Cancer Institute, and colleagues studied 508 medication error incidents that occurred with oral chemotherapy drugs. They identified 99 adverse drug events; 20 were serious or life-threatening and 52 were significant. The researchers also found 322 near misses and 87 errors that posed a low risk of harming patients.

Errors occurred at every stage of the process, but most often occurred during medication ordering (47.2 percent) and dispensing (31.1 percent). Pharmacists were most likely to catch the errors (69.5 percent). Common errors included patients receiving the wrong dose (38.8 percent) or the wrong drug (13.6 percent). Another type of error, supplying patients with the wrong number of days of medication (11 percent), resulted in nearly 40 percent of incidents in which patients suffered an injury. Oral chemotherapy is especially susceptible to this type of dispensing error because of the week-on, week-off schedules and pill combinations required to deliver the correct dose. Standardizing chemotherapy regimens and improving the functionality of computerized order entry so it can be used for oral chemotherapy drugs may help curb these errors, the authors suggest.

This study was funded in part by the Agency for Healthcare Research and Quality (HS17123).

See "Medication errors involving oral chemotherapy," by Dr. Weingart, Julio Toro, R.N., B.S.N., Justin Spencer, M.P.A., and others in the May 15, 2010, Cancer 116 (10), pp. 2455-2464.

Research Activities, November 2010: Safety and Quality of Care: Oral chemotherapy drugs not immune to medication errors

Hospitalizations for Medication and Illicit Drug-related Conditions on the Rise among Americans Ages 45 and Older

Hospitalizations for Medication and Illicit Drug-related Conditions on the Rise among Americans Ages 45 and Older
Press Release Date: October 25, 2010

The number of hospital admissions among Americans ages 45 and older for medication and drug-related conditions doubled between 1997 and 2008, according to a new report released today by the Department of Health and Human Services' (HHS) Agency for Healthcare Research and Quality (AHRQ). Medication and drug-related conditions include effects of both prescription and over-the-counter medications as well as illicit drugs.

Hospital admissions among those 45 years and older were driven by growth in discharges for three types of medication and drug-related conditions—drug-induced delirium; "poisoning" or overdose by codeine, meperidine and other opiate-based pain medicines; and withdrawal from narcotic or non-narcotic drugs.

Admissions for all medication and drug-related conditions grew by 117 percent—from 30,100 to 65,400—for 45- to 64-year-olds between 1997 and 2008. The rate of admissions for people ages 65 to 84 closely followed, growing by 96 percent, and for people ages 85 and older, the rate grew by 87 percent. By comparison, the number of hospital admissions for these conditions among adults ages 18 to 44 declined slightly by 11 percent.

"This report reveals a disturbing trend, and we need to find out more about why these admissions are increasing," said AHRQ Director Carolyn M. Clancy, M.D. "As the average age of hospital patients continues to increase, so does the need for close monitoring of the types and dosages of drugs given to them."

Drug-induced delirium or dementia can be caused by sleeping pills as well as drugs for urinary incontinence, nausea and other problems common in the elderly, but doctors sometimes cannot identify the cause. Poisoning by pain medicines or other drugs containing codeine, meperidine or other opiates can be caused by accidental overdosing or the failure to recognize the drug's active ingredient. Drug withdrawal occurs when there is an abrupt withdrawal or significant reduction in the dosage of pain or other prescription medicines to which a person can become addicted, as well as of illicit drugs.

HHS' Substance Abuse and Mental Health Services Administration helped support the analysis of the data in the report on hospital care for mental health and substance abuse disorders."Substance abuse is rising, and drug abuse of all kinds is exploding as a major public health concern for our country," said SAMHSA Administrator Pamela S. Hyde, J.D. "The challenge for our health care practitioners is to see that patients receive medications when there is medical need but also to help prevent the adverse health consequences from drug use."

The new AHRQ report also shows that Medicare and Medicaid were responsible for 57 percent of the $1.1 billion cost to hospitals in 2008 for treating patients with medication and drug-related conditions, private insurance covered 24 percent, and the uninsured accounted for 14 percent. The remaining 5 percent of hospital costs for treating these conditions were borne by other sources such as TRICARE.

AHRQ's report also includes data on other types of medical conditions treated in U.S. community hospitals, surgical and other procedures, and costs in 2008. For more information, go to HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2008 at http://www.hcup-us.ahrq.gov/reports/factsandfigures/2008/TOC_2008.jsp.

For more information, please contact AHRQ Public Affairs: (301) 427-1855 or (301) 427-1539.

Use Twitter to get AHRQ news updates: http://www.twitter.com/ahrqnews/

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Internet Citation:

Hospitalizations for Medication and Illicit Drug-related Conditions on the Rise among Americans Ages 45 and Older. Press Release, October 25, 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/press/pr2010/hospmedpr.htm

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Hospitalizations for Medication and Illicit Drug-related Conditions on the Rise among Americans Ages 45 and Older


HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2008
HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2008

OMS | La tripanosomiasis africana (enfermedad del sueño)

La tripanosomiasis africana (enfermedad del sueño)

Datos y cifras

* La enfermedad del sueño solo ocurre en 36 países del África subsahariana donde existe la mosca tsetsé que puede transmitirla.
* Las personas que están más expuestas al contacto con la mosca tsetsé y, por consiguiente, a contraer la enfermedad son los habitantes de zonas rurales que se dedican a la agricultura, la pesca, la ganadería o la caza.
* Trypanosoma brucei gambiense causa el 95% de los casos de enfermedad del sueño notificados.
* Gracias a las iniciativas sostenidas de control de la enfermedad, en 2009 el número de casos disminuyó por debajo de 10 000, lo que no había ocurrido en 50 años.
* El diagnóstico y tratamiento de la enfermedad son complejos y exigen la intervención de personal especializado.

Definición de la enfermedad

La tripanosomiasis africana humana, también llamada enfermedad del sueño, es una parasitosis transmitida por un vector. Los parásitos que la causan son protozoos pertenecientes al género Trypanosoma. Son transmitidos a los seres humanos por la picadura de la mosca tsetsé (del género Glossina) que ha contraído la infección de personas o animales que albergan los parásitos patógenos para el ser humano.

La mosca tsetsé se encuentra en el África subsahariana pero solo ciertas especies transmiten la enfermedad; por razones que hasta la fecha no se han explicado, este insecto vive en muchas regiones donde no ocurre la enfermedad del sueño. Las personas que están más expuestas al contacto con la mosca tsetsé y, por consiguiente, a contraer la enfermedad son los habitantes de zonas rurales que se dedican a la agricultura, la pesca, la ganadería o la caza. La enfermedad puede aparecer en zonas que van desde una sola aldea hasta toda un región. Dentro de una zona infectada, la intensidad de la enfermedad puede variar de una aldea a otra.

Las formas de la tripanosomiasis africana humana

La enfermedad adopta dos formas, lo cual depende del parásito causante.

* Trypanosoma brucei gambiense se encuentra en el África occidental y central. Esta forma representa en la actualidad más del 95% de los casos notificados de enfermedad del sueño y causa una infección crónica. Una persona puede estar infectada por meses o incluso años sin presentar manifestaciones clínicas importantes. Cuando los síntomas aparecen, es frecuente que la enfermedad ya esté muy avanzada, en la etapa de afección del sistema nervioso central.
* Trypanosoma brucei rhodesiense se encuentra en el África oriental y del sur. Hoy en día esta forma representa menos del 5% de los casos notificados y causa una infección aguda. Los primeros signos y síntomas se observan a las pocas semanas o a los pocos meses después de la infección. La enfermedad evoluciona rápidamente y afecta al sistema nervioso central.

Hay otra forma de tripanosomiasis que ocurre principalmente en 21 países latinoamericanos; se denomina tripanosomiasis americana o enfermedad de Chagas. El protozoo que la causa pertenece a una especie diferente de la que causa la forma africana de la enfermedad.
La tripanosomiasis animal

Otras especies y subespecies del género Trypanosoma son patógenos para los animales y causan la tripanosomiasis animal en especies silvestres y domesticadas. La enfermedad en el ganado se llama nagana, voz zulú que significa «estar deprimido».

Los animales pueden hospedar los parásitos que son patógenos para el ser humano, especialmente T.b. rhodesiense; por lo tanto, los animales domesticados y silvestres son un reservorio importante. Los animales también pueden infectarse con T.b. gambiense y servir de reservorio; sin embargo, aún no se conoce del todo la función epidemiológica precisa que desempeña este reservorio. La presencia de la enfermedad en los animales domésticos, particularmente el ganado, es un obstáculo importante para el desarrollo económico de las zonas rurales afectadas.
Epidemias importantes en los seres humanos

En los siglos precedentes ha habido varias epidemias en el África.

* Una entre 1896 y 1906, principalmente en Uganda y la cuenca del Congo.
* Otra en 1920, que afectó a varios países africanos.
* La más reciente, que ocurrió en 1970.

La epidemia de 1920 se atajó gracias a la labor de equipos móviles que organizaron el tamizaje de millones de personas en riesgo. A mediados de los años sesenta del siglo pasado, la enfermedad casi había desaparecido. Tras el éxito obtenido, la vigilancia se relajó y en los 30 años últimos la enfermedad ha reaparecido en varias zonas. Los esfuerzos desplegados por la OMS, los programas nacionales de control de la enfermedad, la cooperación bilateral y las organizaciones no gubernamentales en los años noventa del siglo pasado y los comienzo del siglo actual detuvieron y revirtieron la tendencia ascendente en el número de casos nuevos.

Distribución de la enfermedad

La enfermedad del sueño amenaza a millones de personas en 36 países del África subsahariana. Muchas de las poblaciones afectadas viven en zonas remotas con poco acceso a servicios de salud adecuados, lo que obstaculiza la vigilancia y por lo tanto el diagnóstico y tratamiento de los casos. Por añadidura, el desplazamiento de grupos humanos, las guerras y la pobreza son factores que propician el aumento de la transmisión y esto altera la distribución de la enfermedad como consecuencia de la debilidad o inexistencia de los sistemas de salud.

* En 1986, se calculaba que unos 70 millones de personas vivían en zonas donde podía transmitirse la enfermedad.
* En 1988, se notificaron unos 40 000 casos, pero se calcula que 300 000 casos no fueron diagnosticados y por lo tanto no recibieron tratamiento.
* Durante los periodos epidémicos la prevalencia alcanzó un 50% en varias aldeas de la República Democrática del Congo, Angola y el sur del Sudán. La enfermedad del sueño era la primera o segunda causa de muerte en esas comunidades, incluso por delante del sida.
* En 2005, la vigilancia se había reforzado y el número de casos nuevos en el continente se había reducido; entre 1998 y 2004 el número de casos de ambas formas de la enfermedad bajó de 37 991 a 17 616. El número estimado de casos reales se calculó entre 50 000 y
70 000.
* En 2009, gracias a las actividades constantes de control, el número de casos notificados descendió por debajo de 10 000 (9878) por vez primera en 50 años. Actualmente, el número estimado de casos reales es de 30 000.

En 2000 y 2001, la OMS estableció alianzas publicoprivadas con Aventis Pharma (actualmente llamada Sanofi-aventis) y Bayer HealthCare, lo que permitió la creación de un equipo de vigilancia que facilitó apoyo a los países con endemicidad para sus actividades de control y el suministro gratuito de medicamentos para tratar a los enfermos.

En 2006, la alianza se renovó y el éxito logrado en la reducción del número de casos de enfermedad del sueño alentó a otros asociados privados a respaldar el esfuerzo inicial de la OMS con miras a eliminar la enfermedad como problema de salud pública.

Situación actual en los países con endemicidad

La prevalencia varía de un país a otro e incluso en diferentes partes de un país.

* En los 10 años últimos, más del 70% de los casos notificados ocurrieron en la República Democrática del Congo.
* En 2008 y 2009, solo la República Democrática del Congo y la República Centroafricana declararon más de 1000 casos nuevos por año.
* Angola, el Chad, el Sudán y Uganda declararon entre 100 y 1000 casos nuevos por año.
* Países como el Camerún, el Congo, Côte d'Ivoire, el Gabón, Guinea, Guinea Ecuatorial, Kenya, Malawi, Nigeria, la República Unida de Tanzanía, Zambia y Zimbabwe están notificando menos de 100 casos por año.
* A lo largo de más de diez años no se ha notificado ningún caso en Benín, Botswana, Burkina Faso, Burundi, Etiopía, Gambia, Ghana, Guinea Bissau, Liberia, Malí, Mozambique, Namibia, el Níger, Rwanda, el Senegal, Sierra Leona, Swazilandia y el Togo. La transmisión de la enfermedad parece haberse detenido, pero aún es difícil evaluar la situación exacta en algunas zonas a causa de la inestabilidad social o de la dificultad de acceso que entorpece las actividades de vigilancia y diagnóstico.

Infección y cuadro clínico

La enfermedad se transmite principalmente por la picadura de una mosca tsetsé infectada, pero existen otras vías de infección.

* Transmisión de madre a hijo: el tripanosoma puede atravesar la placenta e infectar al feto.
* La transmisión mecánica por intermedio de otros insectos hematófagos es posible; no obstante, es difícil determinar las consecuencias epidemiológicas de esta vía.
* Los pinchazos accidentales con agujas contaminadas en el laboratorio han causado algunas infecciones.

En la primera etapa, los tripanosomas se multiplican en los tejidos subcutáneos, la sangre y la linfa; se conoce como fase hemolinfática y se caracteriza por episodios de fiebre, cefaleas, dolores articulares y prurito.

En la segunda etapa, los parásitos atraviesan la barrera hematoencefálica e infectan el sistema nervioso central; es la etapa de afección nerviosa. Por lo general, es entonces cuando se presentan los signos y síntomas más evidentes de la enfermedad, a saber: cambios de comportamiento, confusión, trastornos sensoriales y falta de coordinación. Los trastornos del ciclo del sueño, que le dan el nombre a la enfermedad, son una característica importante de la segunda etapa. Si no se aplica tratamiento, la enfermedad del sueño es mortal.
Diagnóstico

La atención de la enfermedad se hace en tres pasos.

* Tamizaje de una posible infección. Supone el empleo de pruebas serológicas (solo las hay para T. b. gambiense) y la exploración física en busca de signos clínicos, por lo común, agrandamiento de los ganglios linfáticos del cuello.
* Diagnóstico de la presencia del parásito.
* Determinación de la etapa en que se encuentra la afección. Supone el examen del líquido cefalorraquídeo obtenido por punción lumbar; el resultado ayuda a determinar el tratamiento.

El diagnóstico debe hacerse lo antes posible y antes de la etapa neural para así evitar tratamientos complicados, difíciles y peligrosos.

El carácter prolongado y relativamente asintomático de la primera etapa de la infección por T. b. gambiense es uno de los motivos por los que se requiere el tamizaje activo y completo de la población en riesgo con el fin de identificar tempranamente a los individuos infectados y reducir la transmisión. El tamizaje exhaustivo exige una inversión considerable de recursos humanos y materiales, los cuales suelen escasear en el África, sobre todo en las zonas de difícil acceso donde es más frecuente la enfermedad. Como consecuencia, muchas personas infectadas pueden morir antes de que se las diagnostique y trate.
Tratamiento

El tipo de tratamiento que se administra depende de la etapa de la enfermedad. Los medicamentos que se usan en la primera etapa tienen poca toxicidad y se administran fácilmente. Cuanto más pronto se identifica la enfermedad, mejores son las probabilidades de curación.

El éxito del tratamiento en la segunda etapa depende de un medicamento que atraviese la barrera hematoencefálica para llegar al parásito. Hay cuatro medicamentos registrados para el tratamiento de la enfermedad del sueño; se facilitan gratis en los países donde esta es endémica.

Tratamiento en la primera etapa

* Pentamidina: fue descubierta en 1941; se usa para el tratamiento en la primera etapa de la infección por T.b. rhodesiense. A pesar de que causa unos efectos indeseables de cierta consideración, en general es bien tolerada por los pacientes.
* Suramina: fue descubierta en 1921; se usa para el tratamiento en la primera etapa de la infección por T.b. rhodesiense. Provoca ciertos efectos indeseables en las vías urinarias, así como reacciones alérgicas.

Tratamiento en la segunda etapa

* Melarsoprol: fue descubierto en 1949; se usa contra las dos formas de la infección. Es un derivado del arsénico y produce muchos efectos colaterales indeseables; el peor es la encefalopatía reactiva (síndrome encefalopático), que puede ser mortal (entre 3% y 10%). Se ha observado un aumento de la resistencia a este medicamento en varios focos, particularmente en el África central.
* Eflornitina: es una molécula menos tóxica que el melarsoprol y obtuvo el registro en 1990. Solo es eficaz contra T.b. gambiense. El régimen de tratamiento es estricto y difícil de aplicar.
* En 2009, se introdujo el tratamiento mediante la combinación de nifurtimox y eflornitina, que simplifica el empleo de esta última por comparación con la monoterapia. Por desgracia, no es eficaz contra T.b. rhodesiense. El nifurtimox tiene registro para el tratamiento de la tripanosomiasis americana pero no para la tripanosomiasis africana humana. No obstante, una vez que los ensayos clínicos produjeron los datos de inocuidad y eficacia, su empleo en combinación con la eflornitina se ha aceptado e incluido en la Lista de medicamentos esenciales de la OMS. La Organización distribuye gratuitamente la combinación para este propósito.

La respuesta de la OMS

La OMS ofrece apoyo y asistencia técnica a los programas nacionales de control de esta enfermedad. Una parte importante de la respuesta es la alianza publicoprivada de la OMS con Sanofi-aventis (pentamidina, melarsoprol y eflornitina) y con Bayer AG (suramina y nifurtimox) para proporcionar los medicamentos en forma gratuita a los países donde la enfermedad es endémica. Se ha establecido una red para que los países donantes, las fundaciones privadas, las ONG, las instituciones regionales, los centros de investigación y las universidades participen en la vigilancia y el control y emprendan proyectos de investigación para la obtención de nuevos medicamentos y medios de diagnóstico.

Los objetivos del programa de la OMS son los siguientes:

* fortalecer y coordinar las medidas de control y procurar que las actividades sobre el terreno sean sostenidas:
* fortalecer los sistemas de vigilancia existentes;
* garantizar el acceso al diagnóstico y el tratamiento;
* apoyar el monitoreo del tratamiento y la farmacorresistencia por medio de la red;
* crear bases de datos y efectuar el análisis epidemiológico de los datos;
* llevar a cabo actividades de capacitación;
* apoyar las investigaciones operativas para mejorar los medios de diagnóstico y tratamiento;
* promover la colaboración con la Organización de las Naciones Unidas para la Agricultura y la Alimentación (FAO) en lo concerniente a la tripanosomiasis animal, y con el Organismo Internacional de Energía Atómica (OIEA) con respecto a la lucha antivectorial con moscas esterilizadas por irradiación; la OMS, la FAO y el OIEA, junto con la Unión Africana, promueven el Programa contra la Tripanosomiasis Africana;
* coordinar y procurar la sinergia de las actividades de lucha antivectorial encabezadas por la campaña panafricana de erradicación de la mosca tsetsé y la tripanosomiasis de la Unión Africana.

Para más información puede ponerse en contacto con:

Centro de prensa de la OMS
Teléfono: +41 22 791 2222
E-mail: mediainquiries@who.int

OMS | La tripanosomiasis africana (enfermedad del sueño)

OMS | África aprovecha la oportunidad para luchar contra la poliomielitis

África aprovecha la oportunidad para luchar contra la poliomielitis
Se inmunizarán más de 72 millones de niños en 15 países de África.

26 DE OCTUBRE DE 2010 | DAKAR | BRAZZAVILLE | GINEBRA -- Esta semana África aprovecha una oportunidad sin precedentes para verse libre de la poliomielitis. Para ello, sacando partido de los avances realizados este año, 15 países del continente han lanzado una campaña sincronizada de inmunización masiva que abarcará a 72 millones de niños.

Se han movilizado unos 290 000 vacunadores para que vayan de puerta en puerta administrando dos gotas de vacuna antipoliomielítica oral a todos los menores de 5 años residentes en zonas consideradas de «máximo riesgo» de transmisión de la poliomielitis.

Después de que la enfermedad se propagara de Nigeria a 24 países de África occidental y central y del Cuerno de África, los líderes africanos establecieron una cooperación sin precedentes y se comprometieron a llevar a cabo en 2009 y en marzo y abril de 2010 una serie de actividades de inmunización sincronizadas.

El resultado directo de esas campañas es que ya solo hay alguno que otro brote. En África occidental, solo Liberia y Malí han tenido algunos casos en los últimos 5 meses; en Nigeria (el único país africano en el que nunca se ha detenido la transmisión de la poliomielitis), los casos se han reducido en un 98% el año pasado.
Riesgos de que no se complete la erradicación

En la últimas semanas se ha visto claramente que los riesgos de que no se complete la erradicación son muy reales. En Liberia hubo en septiembre un caso que confirmó la transmisión residual; en Malí hubo una nueva importación de poliovirus salvajes de tipo 3 (la primera desde 2001), y en Uganda, que ha estado libre de poliomielitis desde hace más de un año, también ha habido un caso. Se están realizando en todos los países evaluaciones rápidas para formular un plan de respuesta de emergencia con dos campañas más de barrido. Todos los países de la subregión de África occidental volverán a realizar dos campañas completas en febrero y marzo de 2011, pero las campañas de inmunización de gran calidad tienen que complementarse con una mejora de la inmunización sistemática y un fortalecimiento de la vigilancia de la enfermedad.

Después de que el brote de Angola (25 casos) se propagara a las provincias vecinas de la República Democrática del Congo (28 casos), estos dos países representan ahora la principal amenaza en África, y en ellos se han registrado 48 de los 58 casos que ha habido en el continente en los últimos 6 meses. Pese a todo, en la República Democrática del Congo el virus está confinado geográficamente, y en Angola el porcentaje de niños no vacunados ha bajado en la campaña más reciente (iniciada el 1 de octubre) de cerca del 30% al 13% en el principal reservorio (Luanda), y del 15% al 8% en la totalidad del país, gracias a las medidas adoptadas por el gobierno para corregir la deficiente cobertura vacunal.

El Director Regional de la OMS para África, Dr. Luís G. Sambo, agradeció las medidas adoptadas recientemente por Angola y la República Democrática del Congo para reducir el déficit de cobertura vacunal, y el mismo ministro de Salud de Angola ha salido a las calles de Luanda a vacunar a los niños en la campaña de octubre. «En África estamos obteniendo el apoyo esencial de los gobiernos, que puede establecer la línea de separación entre el éxito y el fracaso. Pero todavía queda mucho por hacer si queremos proteger los impresionantes avances realizados este año», ha dicho el Dr. Sambo.

«Estamos ante una posibilidad apasionante», ha dicho el Dr. Gianfranco Rotigliano, Director Regional del UNICEF para África occidental y central. «Los líderes políticos de África han aceptado el reto planteado por esta temible enfermedad y aquí tenemos los resultados, que muestran lo que se puede conseguir cuando hay liderazgo, alianzas dinámicas y apoyo de los donantes a un problema sanitario tan importante como este. Hemos de proseguir los esfuerzos de vacunación y seguir dando prioridad a las necesidades de los niños africanos.»

Muchos de los voluntarios que saldrán a vacunar a los niños en estas campañas serán miembros de la Asociación Rotaria Internacional, que desde 1985 ha contribuido con cerca de US$ 1000 millones a los esfuerzos por erradicar la poliomielitis. El Sr. Ambroise Tshimbalanga Kasongo, presidente del Comité PolioPlus de la Asociación Rotaria Africana, pidió a los donantes internacionales que no abandonen la tarea y proporcionen los US$ 810 millones que faltan para llevar a cabo el Plan Estratégico de la Iniciativa de Erradicación Mundial de la Poliomielitis, cuyo objetivo consiste en lograr la erradicación mundial de la enfermedad en 2013.

«La consigna de la Asociación Rotaria Internacional es 'Acabemos con la poliomielitis ya'», ha dicho El Sr. Ambroise Tshimbalanga Kasongo, «En África ya se ve su fin, pero todavía no hemos acabado con ella. Sería inaceptable que no llegáramos a la meta por falta de recursos económicos.»

Las actividades sincronizadas en los 15 países costarán aproximadamente US$ 42,6 millones y han sido financiadas por la Fundación Bill y Melinda Gates, los Centros para el Control y la Prevención de Enfermedades (CDC) de los EE.UU., la Agencia de los Estados Unidos para el Desarrollo Internacional, la Asociación Rotaria Internacional, el UNICEF y los Gobiernos de Alemania y Japón.

Actividades de inmunización

Angola y la República Democrática del Congo lanzarán actividades de inmunización a partir del 29 y el 28 de octubre, respectivamente. Las campañas sincronizadas de otros 10 países se iniciarán hoy, 26 de octubre, en Côte d'Ivoire, el 28 de octubre en Benin, Burkina Faso, Gambia, Guinea, Mali, Mauritania, Senegal y Sierra Leona, y el 29 de octubre en Liberia. En el Chad y el Sudán se iniciarán actividades de inmunización el 1 de noviembre, mientras que en Nigeria se inmunizaron en la semana del 23 de octubre más de 29 millones de niños en 20 estados septentrionales de alto riesgo.

La Iniciativa de Erradicación Mundial de la Poliomielitis está encabezada por los gobiernos nacionales, la OMS, la Asociación Rotaria Internacional, los CDC y el UNICEF.

Desde el lanzamiento de la Iniciativa en 1988, la incidencia de la poliomielitis se ha reducido en más de un 99%. En 1988 había cada año más de 350 000 niños víctimas de parálisis en más de 125 países endémicos, mientras que en la actualidad solo quedan cuatro países endémicos: Afganistán, India, Nigeria y Pakistán.
Para más información, puede ponerse en contacto con:

Rod Curtis
OMS Ginebra
Tel.: +41 79 59 59 721
E-mail: curtisr@who.int


Samuel Ajibola
OMS/AFRO
Tel.: +47 241 39378
E-mail: ajibolas@afro.who.int

OMS | África aprovecha la oportunidad para luchar contra la poliomielitis

Los peligros del estrés laboral - lanacion.com

Los excesos en la oficina
Los peligros del estrés laboral
Existe un riesgo probado para la salud de los trabajadores cuando no se tienen en cuenta los signos de alerta que emiten el cuerpo y la mente
Domingo 31 de octubre de 2010 | Publicado en edición impresa

Paula Urién
LA NACION

"Esta actividad es de riesgo, hay constantes presiones, estrés, una gran exigencia física y psíquica. Y no son sólo las horas de trabajo, sino lo que te llevás a la cama." Son palabras de Daniel Scioli, gobernador de la provincia de Buenos Aires, apenas unas horas después de la muerte del ex presidente Néstor Kirchner y que dan cuenta de las repercusiones en la salud a las que puede llevar el trabajo sin límites.

Daniel López Rosetti, presidente de la Sociedad Argentina de Medicina del Estrés, da una definición de este mal. "Se produce estrés cuando las cargas y las demandas psicológicas, sociales y laborales superan la capacidad de respuesta de la persona. Es entonces cuando aparecen manifestaciones físicas a las que hay que prestar atención."

Algunas son: ansiedad, insomnio, irritabilidad, trastornos digestivos, taquicardia, cefalea, cambios en el carácter, dolores musculares, palpitaciones, suba de la presión arterial, miedos. "La vida de las personas se desenvuelve en gran parte en el plano laboral. Una persona que tiene 60 años ha dormido 20 de esos años y ha trabajado y estudiado 30. Por eso el manejo del estrés en el plano trabajo es tan importante", afirma López Rosetti.

Según varios especialistas consultados, las características individuales son determinantes. La personalidad de tipo A pertenece a quienes son más ansiosos, obsesivos, que se toman a pecho situaciones en las que otros responden de manera más calma. "Es muy difícil transformar una personalidad de tipo A: no se puede pretender que un hiperquinético y competitivo se convierta en un rasta. En general sólo intentan modificar patrones de conducta insalubres cuando el cuerpo manifiesta ciertos síntomas. Es difícil, pero sí se pueden cambiar hábitos de vida a través de la psicoterapia", dice el médico especialista en neuropsiquiatría Diego Sarasola.

Y advierte que el factor estrés está en el mismo nivel de riesgo para el cuerpo que el sedentarismo, el tabaquismo y el sobrepeso. Y que en la Argentina, los antidepresivos y ansiolíticos circulan como aspirinas. "Las drogas tendrían que estar siempre supervisadas por médicos ya que bien usadas dan buenos resultados y mal usadas pueden conducir a un mal peor, como deficiencia en la coordinación y en la memoria", dice.

Aunque según López Rosetti quienes sufren más estrés son los trabajadores con poco poder de decisión; una encuesta de Grant Thornton de este año entre más de 7400 dueños de negocios de 36 países dio como resultado que más de la mitad de los dueños de empresas del sector privado en el mundo están estresados. En la Argentina, el 54% de los empresarios indicaron que sus niveles de estrés aumentaron en 2010. Sus principales preocupaciones son las presiones sobre el flujo de caja por lo difícil y caro que resulta el financiamiento y la pérdida de rentabilidad (61%), regulaciones y burocracia (50%), y clima económico y la excesiva carga laboral (ambos, 49 por ciento).

Pero el estrés laboral se presenta en mayor o menor escala en casi todas las profesiones u oficios. En el marco del IX Congreso Internacional de Medicina del Trabajo, Higiene y Seguridad, realizado esta semana y organizado por la Sociedad Argentina de Medicina del Trabajo, su presidente, Roberto Pinto, en una charla con La Nacion, en un intervalo, afirma: "Todos decimos que nuestros trabajos nos estresan. El ser humano tiene estrés y eso es normal. Pero cuando la situación se prolonga lleva al distrés, que puede producir enfermedades físicas y psíquicas de cualquier tipo".

El profesional aclara: "El distrés produce aumento en la presión arterial, aumento de azúcar en sangre, aumento de los latidos. Aumenta el metabolismo y esto puede llevar a enfermedades del corazón y derrames cerebrales, además de trastornos digestivos. Puede producir desde un resfrío hasta cáncer. También diversos problemas psicológicos. Cada vez tenemos menos dudas".

Con respecto a los profesionales que más riesgo tienen, según Pinto, están los periodistas, sobre todo quienes cubren la actualidad; los mineros; los cirujanos, los que trabajan en terapia intensiva; quienes manejan vehículos de todo tipo por aire, tierra y mar; los que manejan armas, como los policías, y los bomberos, entre otros.

El ambiente que rodea al trabajador es vital. "Si se trabaja en una oficina, debe tener buenas condiciones de temperatura, humedad, ventilación o iluminación. Y con quienes se trabaja también influye. Si hay un ambiente psicológico alterado o situaciones como el mobbing, donde se ejerce presión sobre los trabajadores de rango inferior, el riesgo es alto."

Para López Rosetti, la remuneración económica es muy importante, pero el reconocimiento del trabajo realizado juega un rol clave. Además, la jornada laboral de ocho horas, algo que muchas veces no se cumple. El hecho de llevarse trabajo a la casa; de estar conectados permanentemente con teléfonos inteligentes o netbooks, y no tomar la cantidad de días necesarios de vacaciones suman puntos en contra.

Sin dudar, todos los consultados recomiendan hacer una caminata de media hora todos los días; el colesterol bajo control, y una dieta sana, alejada de las grasas. Es decir, nada nuevo: una mente sana en un cuerpo sano.

ESCENARIO
Riesgo

* El estrés puede producir enfermedades cardiovasculares, la primera causa de muerte en la Argentina.

Encuesta

* Una encuesta de Grant Thornton revela que el 54% de los empresarios locales está más estresado este año que el anterior.

Prevención

* Se recomienda que las empresas cuenten con un desfibrilador y que los empleados aprendan reanimación cardiovascular.

Los peligros del estrés laboral - lanacion.com