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1.  Linking quality of healthcare and health-related quality of life of patients with type 2 diabetes: an evaluative study in Mexican family practice 
Objective
To assess the association between quality of care and health-related quality of life among type 2 diabetes patients.
Design
A cross-sectional study assessing the association between quality of care and quality of life using multiple linear regression analysis.
Setting
Family medicine clinics (FMC) (n = 39) of the Mexican Institute of Social Security (IMSS) in Mexico City.
Participants
Type 2 diabetes patients (n = 312), older than 19 years.
Main Outcome Measure(s)
Health-related quality of life was measured using the MOS Short-Form-12 (SF-12); quality of healthcare was measured as the percentage of recommended care received under each of four domains: early detection of diabetes complications, non-pharmacological treatment, pharmacological treatment and health outcomes.
Results
The average quality of life score was 41.4 points on the physical component and 47.9 points on the mental component. Assessment of the quality of care revealed deficiencies. The average percentages of recommended care received were 21.9 for health outcomes and 56.6 for early detection of diabetes complications and pharmacological treatment; for every 10 percent additional points on the pharmacological treatment component, quality of life improved by 0.4 points on the physical component (coefficient 0.04, 95% confidence intervals 0.01–0.07).
Conclusions
There was a positive association between the quality of pharmacological care and the physical component of quality of life. The quality of healthcare for type 2 diabetes patients in FMC of the IMSS in Mexico City is not optimal.
doi:10.1093/intqhc/mzt062
PMCID: PMC3842123  PMID: 24058002
quality measurement, quality management; quality indicators; patient outcomes (health status, quality of life, mortality)
2.  Effects of the expansion of doctors’ offices adjacent to private pharmacies in Mexico: secondary data analysis of a national survey 
BMJ Open  2014;4(5):e004669.
Objectives
To compare the sociodemographic characteristics, reasons for attending, perception of quality and associated out-of-pocket (OOP) expenditures of doctors’ offices adjacent to private pharmacies (DAPPs) users with users of Social Security (SS), Ministry of Health (MoH), private doctor's offices independent from pharmacies and non-users.
Setting
Secondary data analysis of the 2012 National Survey of Health and Nutrition of Mexico.
Participants
The study population comprised 25 852 individuals identified as having had a health problem 15 days before the survey, and a random sample of 12 799 ambulatory health service users.
Outcome measures
Sociodemographic characteristics, reasons for attending healthcare services, perception of quality and associated OOP expenditures.
Results
The distribution of users was as follows: DAPPs (9.2%), SS (16.1%), MoH (20.9%), private providers (15.4%) and non-users (38.5%); 65% of DAPP users were affiliated with a public institution (MoH 35%, SS 30%) and 35% reported not having health coverage. DAPP users considered the services inexpensive, convenient and with a short waiting time, yet they received ≥3 medications more often (67.2%, 95% CI 64.2% to 70.1%) than users of private doctors (55.7%, 95% CI 52.5% to 58.6%) and public institutions (SS 53.8%, 95% CI 51.6% to 55.9%; MoH 44.7%, 95% CI 42.5% to 47.0%). The probability of spending on consultations (88%, 95% CI 86% to 89%) and on medicines (97%, 95% CI 96% to 98%) was much higher for DAPP users when compared with SS (2%, 95% CI 2% to 3% and 12%, 95% CI 11% to 14%, respectively) and MoH users (11%, 95% CI 9% to 12% and 32%, 95% CI 30% to 34%, respectively).
Conclusions
DAPPs counteract current financial protection policies since a significant percentage of their users were affiliated with a public institution, reported higher OOP spending and higher number of medicines prescribed than users of other providers. The overprescription should prompt studies to learn about DAPPs’ quality of care, which may arise from the conflict of interest implicit in the linkage of prescribing and dispensing processes.
doi:10.1136/bmjopen-2013-004669
PMCID: PMC4039785  PMID: 24852298
Primary Care
3.  Evaluation of the quality of antenatal care using electronic health record information in family medicine clinics of Mexico City 
Background
Evaluation of the quality of antenatal care (ANC) using indicators should be part of the efforts to improve primary care services in developing countries. The growing use of the electronic health record (EHR) has the potential of making the evaluation more efficient. The objectives of this study were: (a) to develop quality indicators for ANC and (b) to evaluate the quality of ANC using EHR information in family medicine clinics (FMCs) of Mexico City.
Methods
We used a mixed methods approach including: (a) in-depth interviews with health professionals; (b) development of indicators following the RAND-UCLA method; (c) a retrospective cohort study of quality of care provided to 5342 women aged 12–49 years who had completed their pregnancy in 2009 and attended to at least one ANC visit with their family doctor. The study took place in four FMCs located in Mexico City. The source of information was the EHR. SAS statistical package served for programing and performing the descriptive statistical analysis.
Results
14 ANC quality indicators were developed. The evaluation showed that 40.6% of women began ANC in the first trimester; 63.5% with low-risk pregnancy attended four or more ANC visits; 4.4% were referred for routine obstetric ultrasound, and 41.1% with vaginal infection were prescribed metronidazole. On average, the percentage of recommended care that women received was 32.7%.
Conclusions
It is feasible to develop quality indicators suitable for evaluating the quality of ANC using routine EHR data. The study identified the ANC areas that require improvement; which can guide future strategies aimed at improving ANC quality.
doi:10.1186/1471-2393-14-168
PMCID: PMC4029895  PMID: 24885103
Antenatal care; Quality evaluation; Electronic health record; Family medicine clinics; Mexico
4.  Evaluating quality of care for patients with type 2 diabetes using electronic health record information in Mexico 
Background
Several low and middle-income countries are implementing electronic health records (EHR). In the near future, EHRs could become an efficient tool to evaluate healthcare performance if appropriate indicators are developed. The aims of this study are: a) to develop quality of care indicators (QCIs) for type 2 diabetes (T2DM) in the Mexican Institute of Social Security (IMSS) health system; b) to determine the feasibility of constructing QCIs using the IMSS EHR data; and c) to evaluate the quality of care (QC) provided to IMSS patients with T2DM.
Methods
We used a three-stage mixed methods approach: a) development of QCIs following the RAND-UCLA method; b) EHR data extraction and construction of indicators; c) QC evaluation using EHR data from 25,130 T2DM patients who received care in 2009.
Results
We developed 18 QCIs, of which 14 were possible to construct using available EHR data. QCIs comprised both process of care and health outcomes. Several flaws in the EHR design and quality of data were identified. The indicators of process and outcomes of care suggested areas for improvement. For example, only 13.0% of patients were referred to an ophthalmologist; 3.9% received nutritional counseling; 63.2% of overweight/obese patients were prescribed metformin, and only 23% had HbA1c <7% (or plasma glucose ≤130 mg/dl).
Conclusions
EHR data can be used to evaluate QC. The results identified both strengths and weaknesses in the electronic information system as well as in the process and outcomes of T2DM care at IMSS. This information can be used to guide targeted interventions to improve QC.
doi:10.1186/1472-6947-12-50
PMCID: PMC3437217  PMID: 22672471
5.  Integrative health care model for climacteric stage women: design of the intervention 
BMC Women's Health  2011;11:6.
Background
Climacteric stage women experience significant biological, psychological and social changes. With demographic changes being observed in the growing number of climacteric stage women in Mexico, it is important to improve their knowledge about the climacteric stage and its potential associated problems, encourage their participation in screening programs, and promote the acquisition of healthy lifestyles.
At Mexican health care institutions the predominant health care model for climacteric stage women has a biomedical perspective. Medical doctors provide mostly curative services and have limited support from other health professionals. This study aims to design an integrative health care model (IHCM: bio-psycho-social, multidisciplinary and women-centered) applicable in primary care services aimed at climacteric stage women.
Methods/Design
We present the design, inclusion criteria and detailed description of an IHCM. The IHCM consists of collaborative and coordinated provision of services by a health team, which is involves a family doctor, nurse, psychologist, and the woman herself. The health team promotes the empowerment of women through individual and group counseling on the climacteric stage and health related self-care. The intervention lasts three months followed by a three-month follow-up period to evaluate the effectiveness of the model. The effectiveness of the model will be evaluated through the following aspects: health-related quality of life (HR-QoL), empowerment, self-efficacy and knowledge regarding the climacteric stage and health-related self-care activities, use of screening services, and improvement in lifestyles (regular leisure time physical activity and healthy diet).
Discussion
Participation in preventive activities should be encouraged among women in Mexico. Designing and evaluating the effectiveness of an integrative health care model for women at the climacteric stage, based on the empowerment approach and focus on health-related self-care to improve their HR-QoL is pertinent for current health conditions of this age group.
Trial registration
The study is registered at the ClinicalTrials.gov (NCT01272115).
doi:10.1186/1472-6874-11-6
PMCID: PMC3050836  PMID: 21333027
6.  The family as a determinant of stunting in children living in conditions of extreme poverty: a case-control study 
BMC Public Health  2004;4:57.
Background
Malnutrition in children can be a consequence of unfavourable socioeconomic conditions. However, some families maintain adequate nutritional status in their children despite living in poverty. The aim of this study was to ascertain whether family-related factors are determinants of stunting in young Mexican children living in extreme poverty, and whether these factors differ between rural or urban contexts.
Methods
A case-control study was conducted in one rural and one urban extreme poverty level areas in Mexico. Cases comprised stunted children aged between 6 and 23 months. Controls were well-nourished children. Independent variables were defined in five dimensions: family characteristics; family income; household allocation of resources and family organisation; social networks; and child health care. Information was collected from 108 cases and 139 controls in the rural area and from 198 cases and 211 controls in the urban area. Statistical analysis was carried out separately for each area; unconditional multiple logistic regression analyses were performed to obtain the best explanatory model for stunting.
Results
In the rural area, a greater risk of stunting was associated with father's occupation as farmer and the presence of family networks for child care. The greatest protective effect was found in children cared for exclusively by their mothers. In the urban area, risk factors for stunting were father with unstable job, presence of small social networks, low rate of attendance to the Well Child Program activities, breast-feeding longer than six months, and two variables within the family characteristics dimension (longer duration of parents' union and migration from rural to urban area).
Conclusions
This study suggests the influence of the family on the nutritional status of children under two years of age living in extreme poverty areas. Factors associated with stunting were different in rural and urban communities.
Therefore, developing and implementing health programs to tackle malnutrition should take into account such differences that are consequence of the social, economic, and cultural contexts in which the family lives.
doi:10.1186/1471-2458-4-57
PMCID: PMC539253  PMID: 15571622
7.  Scaling up cancer care for children without medical insurance in developing countries: The case of Mexico 
Pediatric Blood & Cancer  2013;60(2):196-203.
Background
In 2006, the Mexican government launched the Fund for Protection Against Catastrophic Expenditures (FPGC) to support financially healthcare of high cost illnesses. This study aimed at answering the question whether FPGC improved coverage for cancer care and to measure survival of FPGC affiliated children with cancer.
Procedure
A retrospective cohort study (2006–2009) was conducted in 47 public hospitals. Information of children and adolescents with cancer was analyzed. The coverage was estimated in accordance with expected number of incident cases and those registered at FPGC. The survival was analyzed by using Kaplan–Meier survival curves and Cox proportional hazards regression modeling.
Results
The study included 3,821 patients. From 2006 to 2009, coverage of new cancer cases increased from 3.3% to 55.3%. Principal diagnoses were acute lymphoblastic leukemia (ALL, 46.4%), central nervous system (CNS) tumors (8.2%), and acute myeloid leukemia (AML, 7.4%). The survival rates at 36 months were ALL (50%), AML (30.5%), Hodgkin lymphoma (74.5%), Non-Hodgkin lymphoma (40.1%), CNS tumors (32.8%), renal tumors (58.4%), bone tumors (33.4%), retinoblastoma (59.2%), and other solid tumors (52.6%). The 3-year overall survival rates varied among the regions; children between the east and south-southeast had the higher risks (hazard ratio 3.0; 95% CI: 2.3–3.9) and 2.4; 95% CI: 2.0–2.8) of death from disease when compared with those from the central region.
Conclusion
FPGC has increased coverage of cancer cases. Survival rates were different throughout the country. It is necessary to evaluate the effectiveness of this policy to increase access and identify opportunities to reduce the differences in survival.
doi:10.1002/pbc.24265
PMCID: PMC3561702  PMID: 22887842
childhood cancer; developing countries; survival experience

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