2009 convegno malattie rare tamburlini [23 01]
DESCRIPTION
Cure pediatriche nei paesi conscarse risorse: accesso e qualitàTRANSCRIPT
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Cure pediatriche nei paesi con scarse risorse: accesso e qualità
Torino 22.01.09 Patologia immune e malattie orfane
Salute e disuguaglianze
scarse risorse: accesso e qualità
Giorgio Tamburlini
IRCCS Burlo Garofolo Trieste
Simona Di Mario
CEVEAS MOdena
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Outline
� Disuguaglianze nella salute di donne a bambini nei paesi poveri
� Determinanti dell’accesso e implicazioni strategiche
� Determinanti dell’accesso e implicazioni strategiche
� La dimensione della qualità nelle cure pediatriche ospedaliere
� Strumenti di intervento
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Cause ultime di morte, 0-4 anni
Lancet,Vol 365 Marzo 26,2005
Esattamente come nel 1980 le principali cause di morte sono la diarrea, le polmoniti, la malaria, la prematurità, l’asfissia e la sepsi neonatale (73%).
La sola malnutrizione contribuisce al 53% dei decessi:• diarrhoea 61% malaria 57%• pneumonia 52% measles 45%
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Disuguaglianze negli esiti: mortalità sotto i 5 anni (U5MR)
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60%
80%
100%
Stato di implementazione di interventi essenzialibambini <5a che ricevono almeno 6 interventi essenziali, per fascia di reddito e per paese
0%
20%
40%
60%
Poorest 2nd 3rd 4th Least poor
Bangladesh Benin Brazil Cambodia EritreaHaiti Malawi Nepal Nicaragua
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Cure perinatali: il primo passo verso la diseguaglianza
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Le radici della malattia
una radice comune, “distale”:
“Bani guangnay, talkatarey hama” “Bani guangnay, talkatarey hama” (Niger)
La cattiva salute è nipote della povertà
…e diverse radici “prossimali”
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Perché i bambini nei PVS e in particolare i bb
poveri hanno un rischio maggiore di morire
> esposizione = rischio di contrarre malattie
> suscettibilità = resistenza a
BAMBINO SANO
MALATTIA > suscettibilità = resistenza a malattie
< accesso a interventi preventivi
< accesso ai servizi sanitari
< accesso a cure di II° livello
< probabilità di cure appropriate
MALATTIA GRAVE
MORTE
MALATTIA MODERATA
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Esclusione dalle cure : mancanza di domanda, accesso limitato discriminazione
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Il ruolo delle strategie di delivery dei servizi:
dove vanno i benefici?
60
80
100
COVERAGE (%)
Uptake curve of new health technologies
0
20
40
60
1 2 3 4 5 6 7 8TIME
COVERAGE (%)
Wealthy Poor
Victora et al., Lancet, 2003
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15
20
25
30%
pu
blic
exp
end
itu
re
on
hea
lth
I governi spendono più per i ricchi
0
5
10
15
% p
ub
lic e
xpen
dit
ure
o
n h
ealt
h
Poorest Quintile Richest Quintile
Africa East Europe Asia
Preker A, World Bank
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60%
80%
100%C
ove
rag
e am
on
g t
he
po
ore
st
Malawi Iron Tablets in Pregnancy
Mexico Cash
Transfers
Zambia Measles
Campaign
Tanzania Mosquito
Nets SocialMarketing
0%
20%
40%
0% 20% 40% 60% 80% 100%
Benefit incidence (program focus)
Co
vera
ge
amo
ng
th
e p
oo
rest
PRO-POORPRO-RICH
ArgentinaFeeding Center
BangladeshMidwife
Delivery at Health Center
Marketing
% benefits reaching the poorest 20% Victora, 2005
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cosa fa la differenza ?
Between the early 1960s and the early 1990s :
child mortality fell 20 percent in Bangladesh but 65 percent in Sri Lanka,10 percent in Uganda but 50 percent in Kenya, 10 percent in Haiti but nearly 80 percent in Costa Rica 10 percent in Uganda but 50 percent in Kenya, 10 percent in Haiti but nearly 80 percent in Costa Rica
depending on factors such as income gains for the poor, schooling, food security and water and sanitation,
exactly the same factors that allowed a sustained decrease in child mortality in the UK earlier in the 20th century
(Lancet 2005)
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Focalizzarsi sull’apice della piramide non basta
Disease control specific interventions: Health
interventions
Health Systems
Social determinants of exposure and susceptibility to disease and of demand for health
Risk reduction : long term effects, high impact
interventions
Strenghtening health systems
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criticità nelle cure ospedaliere pediatriche
� Il 12-34% dei bambini che arrivano ai Centri di Salute necessitano di cure ospedaliere
� Molti bambini muoiono prima di arrivare all’ospedale
� Il 50-75% delle morti dei bambini in ospedale avviene
entro le prime 24 ore
� La mortalità intraospedaliera è spesso molto elevata
(fino al 30-35%)
Non ha senso il referral system se l’ospedale non ha qualità
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Esempi
Gernaat 1998, Zambia
229 bambini malnutriti� 30% marasma
� 28% marasma/kwashiorkor� 28% marasma/kwashiorkor
� 22% kwashiorkor
� 20% non definito
� 26% case fatality rate
� Muoiono per polmonite, diarrea, ipotermia, setticemia
La mortalità nei malnutriti severi può essere ridotta al 8-9% con interventi semplici
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Studio osservazionale in 7 paesi: Bangladesh,
Repubblica Dominicana, Etiopia, Indonesia,
Filippine, Tanzania, Uganda (IMR tra 32 e 113 xFilippine, Tanzania, Uganda (IMR tra 32 e 113 x
1000)
I dati sono stati raccolti mediante osservazione,
interviste, analisi dei casi ricoverati e delle cartelle
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Ratings of avoidable morbidity and mortality in study hospitals (1 = poor; 2 = fair; 3 = good)
Staff performance and quality of care Facilities and supplies Support servicesHospitalTriage Emergency Ward T + E Ward Pharmacy Laboratory
TH 1 3 1 1 1 2 2 2TH 2 1 3 3 1 3 3 3TH 3 2 2 3 2 2 2 3TH 4 3 3 2 3 3 3 3TH 5 3 3 3 3 3 3 3TH 6 3 1 3 3 3 3 3TH 7 2 2 2 2 2 2 2TH 8 1 2 2 2 2 3 2TH 8 1 2 2 2 2 3 2
DH 1 1 1 1 1 1 3 1DH 2 2 3 3 1 1 1 1DH 3 1 2 2 1 2 3 2DH 4 1 2 3 2 3 3 3DH 5 2 2 2 1 2 2 2DH 6 1 1 2 1 2 3 3DH 7 3 3 2 3 2 3 3DH 8 3 2 2 2 2 3 2DH 9 2 2 3 2 3 3 3DH 10 1 1 2 1 2 2 2DH 11 1 1 3 1 3 3 2DH 12 1 2 2 1 2 2 2DH 13 1 2 2 1 2 2 2
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Risultati
� Nel 76% dei 131 casi gravi osservati (morti o quasi morti) gravi problemi nella qualità delle cure ospedaliere:
– Triage e cure di emergenza (24%)
– Trattamento (50%)
– Monitoraggio e rivalutazione (17%)
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Conclusioni
Una grande proporzione delle morti
ospedaliere in bambini sotto i 5 anni può
essere evitata attraverso un miglioramento
delle conoscenze e delle routines ospedaliere.delle conoscenze e delle routines ospedaliere.
L’uso di uno strumento sufficientemente
agile e standardizzato per il rilievo delle
criticità può essere il primo passo verso il
miglioramento della qualità delle cure
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Promoting quality improvement in health services : 4 essential components
� Standards (produced by professional organizations, international agencies, health authorities, etc.)
� Measurements & assessment tools and methods(of process and outcomes)
� Measurements & assessment tools and methods(of process and outcomes)
� Driving force(s)
� Strategies (methods/incentives)
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Standards: Child health outpatient and inpatient
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Measurement and assessments
� WHO has developed a tool that facilitates a qualitative assessment of paediatric hospital care
� The tool has been extensively used in all regions of the world including Europe (evaluation carried out in Moldova, Russia and Kazakhstan)
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How the tool has been designed
� Based on standards (WHO guidelines)
� Problem oriented: case management and organisational issues
� Action oriented : identification of areas most in need for improvement and plan of action
� Participatory: involves health professionals
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The tool uses a multiple-source data collection matrix providing
A) information from various sources (visit to facilities, examination of clinical records, direct case observation, and interview with staff and mothers)
B) overall view of the quality of care in key areas, B) overall view of the quality of care in key areas, identifying the most critical ones
C) feed back at facility level as well as to central level, on priority actions (organizational changes, regulations, training, guidelines development etc.)
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10 key areas
� Area 1. Referral and Access to hospital� Area 2. Emergency assessment and treatment� Area 3. Respiratory diseases� Area 4. Diarrhoeal diseases� Area 5. Fever conditions
Area 6. Severe malnutrition� Area 6. Severe malnutrition� Area 7. Neonatal care � Area 8. Supportive care� Area 9. Mother and Child Friendly Services� Area 10. Monitoring, discharge and follow-up
For each area, 4 to 8 items and criteria are identified
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Results
Lancet. 2006;367(9514):919-25.
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Paediatric Hospital assessment in NIS countries
Areas assessed No significant problems
Need for some improvement
Need for substantial improvement
Hospital network
Availability beds
Physical structure
Financial accessibility
KAZKAZ MDAMDA RUSRUS
Financial accessibility
Health personnel
Equipment
Drugs, supplies
Triage
Diagnosis neurological
Treatment
Intensive care
Monitoring
Guidelines
Child friendly attitude
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Unnecessary Admissions, Excessive
or Potentially Harmful Drugs
80
100 MDA N=45
KAZ N=53
0
20
40
60
%
No need for hospitalization Dangerous therapies
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•Plasma concentrate•Frusemide•Acetazolamide•“Dehydration”therapy•Glutamic acid•Vitamin B6, B12, B1•Pirazitam•Debazol•Sidoxin•Sodium Bromide•MgSO
“Perinatal damage to the central nervous system”
Over-diagnosis and dangerous treatments
•MgSO4•“Herbal cocktail”•Encephabol•Theophyline•Complamine•Trindol•Nootropil(vasodilator)•Phenobarbitol•Electrophoresis
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A new tool for mothers and newborn babies
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Impact of 24 hour critical care physician staffing on case-mix adjusted mortality in paediatric intensive care.Goh AY, Lancet 2001;357:445-6
Rianimatore presente 24/24 h. in UTI neonatale� SMR si riduce da 1.57 a 0.88 (Rate ratio 0.56, 95%
CI 0.47-0.67)
� Mortality odds ratio 0.234� Mortality odds ratio 0.234
� La disponibilità 24/24 h di un rianimatore è associata al miglioramento degli outocomes e ad un miglior uso delle risorse per le cure intensive pediatriche
Richiede incremento delle risorse
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Vietnam: appropriate management of a pediatric hospital in the context of limited resources
Nguyen TN Med Trop 1995;55:275-80
Adozione dei principi della PHC:
� Focus sulle malattie più frequenti (diarrea, ARI, dengue, malaria, emergenze pediatriche, malnutrizione)
Adozione di linee guida terapeutiche� Adozione di linee guida terapeutiche
� Decentralizzazione (incoraggiano utilizzo PHC)
� Finanziamenti: i poveri non pagano, gli altri contribuiscono (community funding)
In 5 aa 40% di riduzione della mortalità
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Results at PHC level
� The introduction of WHO/UNICEF IMCI strategy, including evidence-based case management protocols for the most common diseases, where it has been implemented, has produced significant improvements.
� Cost of training and need for supervision have been limiting factors.
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Un sistema di revisione e updating continuo: www.ichrc.org
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� Pediatrics 2008; 121(4):e984-92
Quality improvement: revisione di strumenti e metodi: WHO meeting, Indonesia, 2008
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Conclusioni: cosa si deve fare
� Attribuire alla qualità delle cure l’importanza che merita accanto ad altri aspetti (accesso, ecc.) anche rispetto alla dimensione dell’equità
� Definire metodi semplici per valutare la qualità e � Definire metodi semplici per valutare la qualità e identificare realistici obiettivi di miglioramento
� Identificare i partner per dirigere il processo, trovare le risorse ecc.
� Discutere ed identificare una strategia di motivazioneefficace
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Riferimenti bibliografici essenziali
� WHO, Hospital care for children: Guidelines for the management of common illnesses with limited resources. 2005 WHO, Geneva
� Campbell H, Duke T, Weber M, English M, Carai S, Tamburlini G; Global initiatives for improving hospital care for children: state of the art and future prospects. Pediatrics 2008; 121(4):e984-92the art and future prospects. Pediatrics 2008; 121(4):e984-92
� Tamburlini G, Schindler Maggi R, Di Mario S, Vilarim JN, Bernardino L, Neves I, Pivetta S. Assessing quality of paediatric care in developing countries. Asian Journal of Paediatric Practice, 2007, 11(2): 1-11
� Duke T, Keshishiyan E, Kuttumuratova A, Ostergren M, Ryumina I, Stasii E, Weber MW, Tamburlini G. Quality of hospital care for children in Kazakhstan, Moldova, and Russia: systematic observational assessment. Lancet,2006;367:919-25.