Public Health System In Chile Research Articles

Becoming a (Neuro)Migrant: Attachment, Early Stimulation, and the Government of the Future of Chile

The encounters between health institutions, practitioners, and Haitian and Dominican communities have triggered several frictions and conflicts in the public health system in Chile since 2010, especially in maternal child health. In this article, I explore the interactions between health institutions, “psy” technologies, and afro-descendant women registered in the “Chile Crece Contigo” program and how these interactions impact women’s subjectivity and everyday lives. Developmental sciences, especially neurosciences, play a crucial role in the program by promoting comprehensive childhood development. I argue that the entanglements between attachment theory, neurosciences, and epigenetics gained authority for health practitioners and shaped migrants’ representations of motherhood and child-rearing anchored in neurobiology. Although health institutions have encouraged the adoption of “cultural competencies,” practitioners’ interventions have tended to promote a neurobiological understanding of attachment and early stimulation, neglecting moral and contextual aspects involved in migrants’ parenting practices. Interventions have delineated representations of “(ab)normal” motherhood and childhood, shaping moral ideals of children’s development and a migrant citizenship project for the future of Chile. I also argue that by placing concerns on the table about migrant children’s neurobiological development and social vulnerability, the program has shaped what some researchers call the “neuroscience of poverty.”

One hundred years of health in a demographic, epidemiological and public policy context: the transition of childhood morbidity and its challenges

Chile is in an advanced stage of demographic and epidemiological transition. It is in this scenario that the political, economic and health crisis occurred, with the social outbreak in 2019 and then the COVID-19 pandemic. The mortality of children and adolescents dropped significantly, however, changes in lifestyles and demotivation, associated with long confinement and worsening health of parents and caregivers triggered an epidemic of mental health, developmental and nutritional problems. Pediatricians were forced to reinvent themselves, exposing themselves to stress and burnout. The aim of the manuscript is to describe the demographic, epidemiological and public policy context of child health in Chile in the last century, as a backdrop to dimension the immediate impact of the COVID-19 pandemic. The new health challenges for this age group in the medium and long term are discussed. Some theories, conceptualizations, and relevant milestones of the public health system in Chile are presented. The emergence of "post-pandemic morbidity", such as sedentary lifestyle, food insecurity, screen addiction, identity conflicts, violence, mental health disorders and reemergence of morbidity and mortality due to infectious and contagious diseases is discussed. Professionals responsible for the care of children must redouble their efforts to provide comprehensive care, accompanying families in the new challenges, in order to rehabilitate a healthy childhood.

Incidencia del Traumatismo Dentoalveolar en pacientes atendidos por el Sistema de Salud Pública en Chile

Objetivo. Los traumas dentoalveolares constituyen un conjunto de lesiones que comprometen los dientes o a sus estructuras periodontales (producto de impactos violentos, directos o indirectos). Constituyen un problema de salud pública a nivel mundial. Describir la tendencia de la incidencia del traumatismo dentoalveolar según grupos etarios en pacientes Fondo Nacional de Salud reportados en Atención Primaria en Salud y Centros de Especialidades en Chile durante el periodo 2008-2018. Métodos: La investigación realizada en el presente trabajo es de tipo descriptivo transversal. Fueron calculadas las tasas de incidencia específicas por edad entre los años 2008 hasta 2014 de la Atención Primaria de Salud y estas mismas tasas en los Centros de Especialidad entre los años 2009-2018. Resultados: Los resultados obtenidos nos permiten observar que la tendencia en APS disminuyó de forma progresiva y en Centros de Especialidad aumentó en todos los años, excepto en el rango etario de 20-64 años. En este último caso, el número de años estudiados permitió la estimación de proyecciones de las tasas de incidencia hacia los años 2019-2021, que indican que habría un aumento. Conclusiones: El registro de traumas dentoalveolares en Chile en el Sistema de Salud Pública es deficiente para realizar investigaciones con poblaciones representativas. Lo que dificulta la comprensión de la epidemiología y la determinación de estrategias adecuadas.

Diffuse Large B-Cell Lymphoma in Chile: The Impact of Combined CHOP Plus Rituximab in the Public Health System.

Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoma subtype. The purpose of this study was to evaluate the clinical features, prognostic factors, and results of DLBCL that was treated in the cancer centers of the public health system in Chile and compare cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) with rituximab with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). Patients age > 15 years who were treated in 18 cancer centers in the country between 2001 and 2017 were included. The Kaplan-Meier method was used to calculate overall survival (OS), and Cox proportional hazard regression modeling was used to evaluate the effect of the addition of rituximab to CHOP on OS. A total of 1,807 patients were evaluated. The median age at diagnosis was 62 (range, 15-95) years, with a female predominance (53%). Half of the patients were age ≥ 60 years. Serology for HIV infection was positive in 5% of cases (96 cases). International Prognostic Index scores were available for 90% of patients, of which 45% had low-risk, 25% low-intermediate-risk, 18% high-intermediate-risk, and 11% high-risk scores. CHOP was administered to 986 patients (55%; median follow-up, 13.2 years) and R-CHOP to 821 patients (45%; median follow-up, 8.4 years). R-CHOP was associated with superior OS compared with CHOP (5-year 66% v 48%, and 10-year 53% v 35%; P < .001). Rituximab improved the survival of patients with DLBCL diagnosed and treated in Chile. The benefit was sustained over time, with curative rates of > 50%. This intervention shows that the inclusion of this biological drug justified the expenses incurred by the Ministry of Health in the National Lymphoma Protocols in Chile.

Impact of a high-risk multimorbidity integrated care implemented at the public health system in Chile

During recent years, multimorbidity has taken relevance because of the impact of causes in the system, people, and their families, which has been a priority in the health care plan. Interventions strategies and their implementation are still an emerging topic. In this context, Centro de Innovación en Salud ANCORA UC, together with Servicio de Salud Metropolitano Sur Oriente, implemented as a pilot study High-Risk Multimorbidity Integrated Care strategy. This study aimed to evaluate the impact of this strategy in terms of health services utilization and mortality. A cohort study was conducted with high-risk patients with multimorbidity, stratified by ACG®, intervened between April 2017 and December 2019. The studied population was 3,933 patients who belonged to similar size and location primary care centers. The impact analysis was performed used generalized linear models. Results showed that intervened patients had a significantly lower incidence in mortality (OR 0.56; 95% CI 0.40–0.77), hospital admissions, length of stay, and the number of hospital emergency consultancies. With the proper barriers and facilitators of a real context intervention, the implementation process allowed the systematization and consolidation of the intervention provided in this study. The training for new roles and the constant implementation support from the Centro de Innovación en Salud ANCORA UC team were essential in the progress and success of the intervention. A complete description of the high-risk intervention strategy is provided to contribute to this emerging topic and facilitate its scale-up. We can conclude that this complex intervention was feasible to be implemented in a real context. The Ministry of Health has taken the systematization and consolidation of the conditions for the national scale-up.

Epidemiology of Parkinson’s Disease in Chile

Introduction: Parkinson’s disease (PD) is one of the most common neurodegenerative disorders. There is no epidemiological description of PD in Chile and not many descriptions in Latin America. This study aims to describe the incidence and prevalence of PD in Chile. Methods: The study group was the population on the public health system in Chile between 2010 and 2018 that were registered in the GES system as having PD. Crude and standardized prevalence and incidence were calculated with a 95% confidence interval. Results: 33,345 patients were found in the register as confirmed cases with PD. The crude incidence in 2018 was 23.7/100,000; the crude prevalence in 2018 was 160.7/100,000. The male-to-female ratio was 1.03. Conclusion: The prevalence and incidence observed in the Chilean population are consistent with studies from other countries.

Perioperative chemotherapy in locally advanced gastric cancer in Chile: from evidence to daily practice.

Gastric cancer (GC) is a leading cause of cancer death in Chile. Although recommended in international guidelines since 2006, perioperative chemotherapy was not available to patients in the public health system in Chile until 2016. We conducted an observational study to assess the feasibility of this strategy in public hospitals in Chile (Observational Study of Perioperative Chemotherapy in Locally Advanced Gastric Cancer – PRECISO). Patients with locally advanced, operable GC were offered to receive preoperative chemotherapy with Epirubicin + Cisplatin + Capecitabine (ECX) for three cycles followed by curative surgery. Staging included abdominal CT scan and laparoscopy if peritoneal carcinomatosis was suspected. Postoperative ECX for three cycles was recommended. Between August 2010 and March 2013, 110 patients were screened and 61 enrolled. Median age was 62 years (23–76 years) and most patients had good performance status at baseline (Eastern Cooperative Oncology Group performance status score (ECOG) 0: 42, ECOG 1: 19). Tumour site was proximal in 32 (52%) and medial and distal in 29 (48%) patients. All but four patients (n = 57, 93%) completed three cycles of preoperative chemotherapy. Fifty-six patients were operated and 54 (89%) had a curative resection. Thirty-three patients (54%) had pT0-2, and 18 (30%) had pN0 tumours, with two patients achieving a complete response. As of 20 December 2020, 39 patients died, 32 due to GC, one within 30 days of surgery, two due to intestinal obstruction at 5 and 3 months after surgery and four due to other causes. Five-year survival rate was 38%. We conclude that perioperative chemotherapy is feasible in public hospitals in Chile and should be offered to patients with locally advanced GC.

Mortality from AIDS and tuberculosis-HIV coinfection in the Chilean AIDS Cohort of 2000-2017.

This article aims to assess the sociodemographic and epidemiological factors associated with AIDS and tuberculosis-HIV coinfection mortality in the Chilean adult population between 2000 and 2017. This is a retrospective observational study, evaluating the incidence density of TB-HIV coinfection mortality in the population over 14 years of age. We used data from the Chilean AIDS Cohort database, 17,512 people enrolled in highly active antiretroviral therapy in the public health system in Chile. The Kaplan-Meier survival function and Cox regression were applied. Incidence density of 0.05 for 39,283 person-years for mortality with TB-HIV coinfection was recorded, with an increase in new cases in people living with AIDS among Aymara and Mapuche indigenous populations. Risk factors included CD4 < 500 cells/mm3 (HR = 3.2; 95%CI: 2.2-4.9), viral load at the start of treatment > 10,000 copies/uL (HR = 1.3; 95%CI: 1.2-1.6). Having high school or higher education (HR = 0.76; 95%CI: 0.6-0.9) is a protective factor for mortality for coinfection. Mortality was concentrated in TB-HIV coinfected people with increasing mortality among women and indigenous populations. The paper contributes to the growing recognition of the role of social determinants in disease outcomes, and the requirement to improve community-focused and community-based testing, sex education in schools, and structural interventions to reduce the adult mortality in Chilean population.

Mediation in public healthcare: opportunities for improvement

Mediation in healthcare is a non-adversarial process to resolve a dispute risen between patients and health providers during medical attention Aim: To characterize the mediation process taking place in the public health system in Chile, from its start until 2017. Cross-sectional descriptive study. Under the Transparency Law, information about mediation processes between 2005 and 2017 was requested to the State Defense Council (CDE in its Spanish acronym). This data was complemented with the information available on the website of this agency. Ninety four percent of the complaints filed at the CDE were deemed eligible for mediation. Only 19% of the concluded cases led to an agreement between the disputing parties. The agreements reached were mostly monetary compensation, medical assistance, and apologies/explanation of the facts. The average amount of compensation reached $14,862,088 (Chilean pesos). The most commonly claimed damage resulting from medical care was partial disability. The medical specialties more often claimed were Obstetrics and Gynecology, General Surgery, and Internal Medicine. The analysis of conducted mediations is a source of feedback for healthcare staff and health institutions. It would greatly contribute to prevent possible damage and medical conflicts, specially within the specialties with the most complaints. Improvements to the existing legislation are required to ensure free access for all the population.

Hypertensive disorders during pregnancy associates with maternal pre-gestational obesity in women attended in the public health system in Chile between 2015-2017

Hypertensive disorders during pregnancy associates with maternal pre-gestational obesity in women attended in the public health system in Chile between 2015-2017

Pregestational overweight/obesity are associated with C-section and with LGA newborn in women attended in the public health system in Chile between 2015-2017*

La espironolactona es un diurético ahorrador de potasio con efecto antiandrogénico, de bajo coste y con un buen perfil de seguridad. Hemos observado en nuestra experiencia que es un fármaco infrautilizado en dermatología, pese a que existe evidencia de su uso en diversas patologías dermatológicas, especialmente en el acné femenino (nivel de evidencia ii-iii, fuerza de recomendación B), donde podría disminuir el uso de antibióticos y probablemente de isotretinoína. Otras enfermedades en las cuales puede ser útil son la hidrosadenitis supurativa y la alopecia androgenética femenina. Discutimos las indicaciones de la espironolactona, su dosificación en la práctica dermatológica, las precauciones que deben tener en cuenta y sus efectos secundarios. Además, presentamos nueva evidencia que avala su uso en dermatología sin necesidad de indicar pruebas complementarias en mujeres jóvenes y enfatiza su seguridad a largo plazo. Consideramos que la espironolactona debería estar entre los agentes comúnmente utilizados en la práctica clínica habitual.Spironolactone is an economical potassium-sparing diuretic with an anti-androgenic effect and a good safety profile. Our experience suggests that this diuretic is underexploited in dermatology even though there is evidence supporting its use in several skin conditions. When prescribed for acne in female patients (level 1–2 evidence; strength of recommendation, B), for example, it can reduce the need for antibiotics and possibly isotretinoin. Other diseases in which spironolactone is potentially useful are hidradenitis suppurativa and female androgenetic alopecia. We discuss the indications for spironolactone, dosing in dermatology, precautions to consider, and adverse effects. We also review new evidence that stresses the safety of long-term therapy and supports the use of this drug without the need for complementary testing in young women. We think that spironolactone merits a place among the medications commonly used in routine clinical practice.

Cost-Effectiveness of Exercise-Based Cardiac Rehabilitation in Chilean Patients Surviving Acute Coronary Syndrome.

To assess the cost-effectiveness of 3 models of exercise-based cardiac rehabilitation (CR) compared with standard care in survivors of acute coronary syndrome (ACS) within the public health system in Chile. A Markov model was designed using 5 health states: ACS survivor, second ACS, complications, general mortality, and cardiovascular mortality. The transition probabilities between health states for standard care and corresponding relative risk for CR were calculated from a systematic review. Health benefits were measured with the EuroQol 5-dimensional 3-level (EQ-5D-3L) survey. Costs for each health state were quantified using the national cost verification study. The CR cost was estimated with a microcosting methodology. The time horizon was a lifetime and the discount rate was 3% per year for costs and benefits. Deterministic and probabilistic analyses were performed. Structural uncertainty was managed by designing 3 scenarios: CR as currently delivered in a specific Chilean public health center, CR as recommended by South American guidelines, and CR as proposed for low-resource settings. Cardiac rehabilitation versus standard care showed an incremental cost-effectiveness ratio for the standard model of $722, for the South American model of $1247, and for the low-resource model of $666. The tornado diagram showed higher uncertainty in relative risk for the complications state and for the second ACS state. Considering a cost-effectiveness threshold of 1 unit of gross domestic product per capita (∼$19 000), CR is highly cost-effective for the public health system in Chile.

Extranodal lymphomas in the public health system in Chile: Analysis of 1251 patients from the National Adult Cancer Program.

The aim of the study was to describe the clinical and epidemiological characteristics, anatomic and histologic distribution, and treatment results of extranodal lymphomas (ENLs), diagnosed and treated in the public health system in Chile. We included patients with ENL diagnosed from 1998 to 2014, in 17 cancer centers, registered prospectively in the database of the National Adult Cancer Program (PANDA) of the Ministry of Health. Treatment was based on the local protocols for each lymphoma subtype. Extranodal lymphoma was documented in 1215 of 4907 non-Hodgkin lymphomas diagnosed in that period (25%). Median age was 59years (range, 16-95), and 55% were female. The gastrointestinal (GI) tract was the most common location (38%), followed by the head and neck (24%) and the skin (15%). B-cell lymphomas accounted for 78% of cases, diffuse large B-cell lymphoma being the most common histologic subtype (68%). Mycosis fungoides/Sezary syndrome was the most frequent T-cell subtype (36%), followed by NK/T-cell lymphomanasal type (24%). In comparison with western countries, Chile showed a significantly high prevalence of NK/T-cell lymphoma nasal type, while the frequency of B-cell ENL and the anatomic distribution appeared similar, being GI the most commonly involved site.

Successful initial experience with a novel outpatient total hip arthroplasty program in a public health system in Chile.

The aim of the present study was to assess the first experience with outpatient total hip arthroplasty (THA) in a public health environment in Chile. Prospective series of the first 69 patients/72 hips. Surgery wasperformed in a public university-affiliated hospital. The patients were 64 (31-84) years old and healthy (ASA I-II) candidates for a primary hip arthroplasty. The outpatient track had 52.2% of arthroplasty candidates included and 94.4% (68/72 hips) were successfullydischarged the same day. There were no emergency room visits during the first week after surgery. Two patients had single dislocation episodes, one requiring stem revision. There was one deep vein thrombosis. There were no other complications. All the patients reported to be satisfied with the outpatient track. An outpatient track can be developed in a safe manner in this healthcare setting and population. This track of care was well accepted by the patients.

Optimal Guidelines for Screening Mammography Based on Individual Risk Factors

Early diagnosis is effective in reducing the death rate and treatment costs due to breast cancer. Although there is consensus that mammograms are effective for early diagnosis, not all organizations agree upon screening guidelines. Current guidelines from the American Cancer Society recommend an annual mammography starting at age 40. In contrast, the public health system in Chile guarantees two screening mammograms between the ages of 50 and 54. The objective of this paper is to study optimal individualized mammography guidelines that enable dynamic tracking of patients’ risk factors, from the perspective of the public health system. We develop a stochastic dynamic programming model to minimize the total expected lifetime cost, including screening and treatment. The optimal number of screening mammograms derived from our model falls between the American Cancer Society and Chilean recommendations. However, when addressing the average breast-cancer risk, the optimal screening policy is either too aggressive for low-risk women or too conservative for high-risk women. Our results also show that it is beneficial to segment the population based on risk levels and to develop screening guidelines accordingly. Finally, sensitivity analysis indicates that optimal policies are sensitive to the costs of mammogram and treatments. This might explain why different countries have such a difference in screening polices. Thus, importing successful guidelines from other countries should not be recommended due to differences in costs of equipment and labor, and also in population genetics, lifestyles and environments.

Development of a distance education program in the public health system in Chile, 2004-2009

This paper reports the gradual development and results achieved in the distance education program set up in the Public Health System in Chile in 2004. Up to date, more than 22,000 students from 29 different health divisions have been trained. This strategy was designed to provide more flexibility and diversity to the training programs of the Health System within the framework of a deep and complex organizational change promoted by Health Reform. The main results show that the integration of organizational, teaching, logistic and budgetary aspects has turned out to be a key element in its success, validating the relevance of the provided solutions. The access to training by means of e-learning or blended learning (electronic education that includes traditional and distance learning activities) allowed employees to choose more independently what, where and when to study. This fact accounts for the high demand for this program. Through this initiative, the National Health System, introduced a wider scope of responses to training needs, which will mean a better adaptation to the challenges associated to health care.

Desarrollo de un sistema de educación a distancia en el sector público de salud: 2004-2009

This paper reports the gradual development and results achieved in the distance education program set up in the Public Health System in Chile in 2004. Up to date, more than 22,000 students from 29 different health divisions have been trained. This strategy was designed to provide more flexibility and diversity to the training programs of the Health System within the framework of a deep and complex organizational change promoted by Health Reform. The main results show that the integration of organizational, teaching, logistic and budgetary aspects has turned out to be a key element in its success, validating the relevance of the provided solutions. The access to training by means of e-learning or blended learning (electronic education that includes traditional and distance learning activities) allowed employees to choose more independently what, where and when to study. This fact accounts for the high demand for this program. Through this initiative, the National Health System, introduced a wider scope of responses to training needs, which will mean a better adaptation to the challenges associated to health care.

Índice de medicina preventiva: Una medida integradora de la cobertura de los programas preventivos

Preventive activities of the public health system in Chile are not integrated and there is no parameter assessing the whole population that is benefited with these activities. To develop and implement a mathematical measure of the coverage of preventive health activities, provided to different age groups. Data was gathered from the monthly statistical reports of the women, children, teenager, adult and elderly health programs in 30 communities of the Seventh Chilean Region. The preventive medicine index (PMI) was calculated as the ratio between the population that was ascribed to each program and the population that was a potential beneficiary of such program. In the studied region, the global coverage of preventive medicine, calculated using the PMI, increased from 0.229 in 1999 to 0.370 in 2003. This represents a 61% increment. However, there are important inequalities in the access to preventive health in the different communities of the region. The PMI revealed a substantial increment in preventive health activities in the studied region.