Tomas Pantoja

Análisis crítico de un artículo Las estatinas reducen la morbi-mortalidad en pacientes de alto riesgo cardiovascular: Heart Protection Study Collaborative Group. (HPS). Lancet 2002; 360: 7-22.

: Throughout the usual LDL cholesterol range in Westernpopulations, lower blood concentrations are associated with lower cardiovascular disease risk.In such populations, therefore, reducing LDL cholesterol may reduce the development of vascu-lar disease, largely irrespective of initial cholesterol concentrations.

Supporting the delivery of cost-effective interventions in primary health-care systems in low-income and middle-income countries: an overview of systematic reviews

Strengthening health systems is a key challenge to improving the delivery of cost-effective interventions in primary health care and achieving the vision of the Alma-Ata Declaration. Effective governance, financial and delivery arrangements within health systems, and effective implementation strategies are needed urgently in low-income and middle-income countries. This overview summarises the evidence from systematic reviews of health systems arrangements and implementation strategies, with a particular focus on evidence relevant to primary health care in such settings. Although evidence is sparse, there are several promising health systems arrangements and implementation strategies for strengthening primary health care. However, their introduction must be accompanied by rigorous evaluations. The evidence base needs urgently to be strengthened, synthesised, and taken into account in policy and practice, particularly for the benefit of those who have been excluded from the health care advances of recent decades.

Implementation research evidence uptake and use for policy-making

A major obstacle to the progress of the Millennium Development Goals has been the inability of health systems in many low- and middle-income countries to effectively implement evidence-informed interventions. This article discusses the relationships between implementation research and knowledge translation and identifies the role of implementation research in the design and execution of evidence-informed policy. After a discussion of the benefits and synergies needed to translate implementation research into action, the article discusses how implementation research can be used along the entire continuum of the use of evidence to inform policy. It provides specific examples of the use of implementation research in national level programmes by looking at the scale up of zinc for the treatment of childhood diarrhoea in Bangladesh and the scaling up of malaria treatment in Burkina Faso. A number of tested strategies to support the transfer of implementation research results into policy-making are provided to help meet the standards that are increasingly expected from evidence-informed policy-making practices.

Health equity: evidence synthesis and knowledge translation methods

BackgroundAt the Rio Summit in 2011 on Social Determinants of Health, the global community recognized a pressing need to take action on reducing health inequities. This requires an improved evidence base on the effects of national and international policies on health inequities. Although systematic reviews are recognized as an important source for evidence-informed policy, they have been criticized for failing to assess effects on health equity.MethodsThis article summarizes guidance on both conducting systematic reviews with a focus on health equity and on methods to translate their findings to different audiences. This guidance was developed based on a series of methodology meetings, previous guidance, a recently developed reporting guideline for equity-focused systematic reviews (PRISMA-Equity 2012) and a systematic review of methods to assess health equity in systematic reviews.ResultsWe make ten recommendations for conducting equity-focused systematic reviews; and five considerations for knowledge translation. Illustrative examples of equity-focused reviews are provided where these methods have been used.ConclusionsImplementation of the recommendations in this article is one step toward monitoring the impact of national and international policies and programs on health equity, as recommended by the 2011 World Conference on Social Determinants of Health.

Health care reform in Chile

Chile has maintained a dual health care system under which its citizens can voluntarily opt for coverage by either the public National Health Insurance Fund or any of the countrys private health insurance companies. Currently, 68% of the population is covered by the public fund and 18% by private

Capturing lessons learned from evidence-to-policy initiatives through structured reflection

BackgroundKnowledge translation platforms (KTPs), which are partnerships between policymakers, stakeholders, and researchers, are being established in low- and middle-income countries (LMICs) to enhance evidence-informed health policymaking (EIHP). This study aims to gain a better understanding of the i) activities conducted by KTPs, ii) the way in which KTP leaders, policymakers, and stakeholders perceive these activities and their outputs, iii) facilitators that support KTP work and challenges, and the lessons learned for overcoming such challenges, and iv) factors that can help to ensure the sustainability of KTPs.MethodsThis paper triangulated qualitative data from: i) 17 semi-structured interviews with 47 key informants including KTP leaders, policymakers, and stakeholders from 10 KTPs; ii) document reviews, and iii) observation of deliberations at the International Forum on EIHP in LMICs held in Addis Ababa in August 2012. Purposive sampling was used and data were analyzed using thematic analysis.ResultsDeliberative dialogues informed by evidence briefs were identified as the most commendable tools by interviewees for enhancing EIHP. KTPs reported that they have contributed to increased awareness of the importance of EIHP and strengthened relationships among policymakers, stakeholders, and researchers. Support from policymakers and international funders facilitated KTP activities, while the lack of skilled human resources to conduct EIHP activities impeded KTPs. Ensuring the sustainability of EIHP initiatives after the end of funding was a major challenge for KTPs. KTPs reported that institutionalization within the government has helped to retain human resources and secure funding, whereas KTPs hosted by universities highlighted the advantage of autonomy from political interests.ConclusionsThe establishment of KTPs is a promising development in supporting EIHP. Real-time lesson drawing from the experiences of KTPs can support improvements in the functioning of KTPs in the short term, while making the case for sustaining their work in the long term. Lessons learned can help to promote similar EIHP initiatives in other countries.

A cost-effectiveness evaluation of a home visit program for adolescent mothers

A home visit intervention program for adolescents throughout their pregnancy and during the early stages of motherhood was evaluated. The participants (N = 90) were part of a larger group of adolescents treated in two health centers in a poor neighborhood in Santiago, Chile. The program was carried out by volunteer community health monitors and evaluated through an experimental, randomized, controlled clinical trial. Cost-effectiveness was examined in comparison with standard health care. Results show higher scores for the intervention group on the mothers’ mental health and nutritional state, as well as on the children’s levels of linguistic development.

Advancing the field of health systems research synthesis

Those planning, managing and working in health systems worldwide routinely need to make decisions regarding strategies to improve health care and promote equity. Systematic reviews of different kinds can be of great help to these decision-makers, providing actionable evidence at every step in the decision-making process. Although there is growing recognition of the importance of systematic reviews to inform both policy decisions and produce guidance for health systems, a number of important methodological and evidence uptake challenges remain and better coordination of existing initiatives is needed. The Alliance for Health Policy and Systems Research, housed within the World Health Organization, convened an Advisory Group on Health Systems Research (HSR) Synthesis to bring together different stakeholders interested in HSR synthesis and its use in decision-making processes. We describe the rationale of the Advisory Group and the six areas of its work and reflects on its role in advancing the field of HSR synthesis. We argue in favour of greater cross-institutional collaborations, as well as capacity strengthening in low- and middle-income countries, to advance the science and practice of health systems research synthesis. We advocate for the integration of quasi-experimental study designs in reviews of effectiveness of health systems intervention and reforms. The Advisory Group also recommends adopting priority-setting approaches for HSR synthesis and increasing the use of findings from systematic reviews in health policy and decision-making.

Reviews of qualitative evidence: a new milestone for Cochrane.

Systematic reviews addressing a wide range of healthcare questions and drawing on a range of different study designs are increasingly available in the literature. The Cochrane Database of Systematic Reviews currently considers Cochrane Reviews on the effectiveness of health interventions and the accuracy of screening and diagnostic tests as well as overviews of reviews and methodology reviews. November 2013 marks an important milestone for The Cochrane Collaboration with the publication of a review of qualitative studies. This synthesis of qualitative evidence addresses barriers and facilitators to the implementation of lay health worker (LHW) programmes. Findings from this synthesis have been integrated with outcomes from the Cochrane effectiveness review on the use of LHWs in primary and community health care for maternal and child health providing a comprehensive assessment of this strategy. The synthesis of qualitative evidence makes an important contribution to the knowledge available to organisations such as the World Health Organization (WHO) when developing international recommendations on public health topics. Organisations need to consider whether their recommendations especially on issues related to the organisation of care are likely to be feasible and acceptable to care providers and communities and they need to consider the challenges for their implementation. (Excerpts)

Protocol for the development of a CONSORT-equity guideline to improve reporting of health equity in randomized trials

BackgroundHealth equity concerns the absence of avoidable and unfair differences in health. Randomized controlled trials (RCTs) can provide evidence about the impact of an intervention on health equity for specific disadvantaged populations or in general populations; this is important for equity-focused decision-making. Previous work has identified a lack of adequate reporting guidelines for assessing health equity in RCTs. The objective of this study is to develop guidelines to improve the reporting of health equity considerations in RCTs, as an extension of the Consolidated Standards of Reporting Trials (CONSORT).Methods/designA six-phase study using integrated knowledge translation governed by a study executive and advisory board will assemble empirical evidence to inform the CONSORT-equity extension. To create the guideline, the following steps are proposed: (1) develop a conceptual framework for identifying “equity-relevant trials,” (2) assess empirical evidence regarding reporting of equity-relevant trials, (3) consult with global methods and content experts on how to improve reporting of health equity in RCTs, (4) collect broad feedback and prioritize items needed to improve reporting of health equity in RCTs, (5) establish consensus on the CONSORT-equity extension: the guideline for equity-relevant trials, and (6) broadly disseminate and implement the CONSORT-equity extension.DiscussionThis work will be relevant to a broad range of RCTs addressing questions of effectiveness for strategies to improve practice and policy in the areas of social determinants of health, clinical care, health systems, public health, and international development, where health and/or access to health care is a primary outcome. The outcomes include a reporting guideline (CONSORT-equity extension) for equity-relevant RCTs and a knowledge translation strategy to broadly encourage its uptake and use by journal editors, authors, and funding agencies.