Perinatal mortality and quality of care at the National Institute of Perinatology: A 3-year analysis

Quality of medical care has been indirectly assessed through the collection of negative outcomes. A preventable death is one that could have been avoided if optimum care had been offered. The general objective of the present project was to analyze the perinatal mortality at the National Institute of Perinatology (located in Mexico City) by social, biological and some available components of quality of care such as avoidability, provider responsibility, and structure and process deficiencies in the delivery of medical care. A Perinatal Mortality Committee data base was utilized. The study population consisted of all singleton perinatal deaths occurring between January 1, 1988 and June 30, 1991 (n = 522). A proportionate study was designed.^ The population studied mostly corresponded to married young adult mothers, who were residents of urban areas, with an educational level of junior high school or more, two to three pregnancies, and intermediate prenatal care. The mean gestational age at birth was 33.4 $\pm$ 3.9 completed weeks and the mean birthweight at birth was 1,791.9 $\pm$ 853.1 grams.^ Thirty-five percent of perinatal deaths were categorized as avoidable. Postnatal infection and premature rupture of membranes were the most frequent primary causes of avoidable perinatal death. The avoidable perinatal mortality rate was 8.7 per 1000 and significantly declined during the study period (p $<$.05). Preventable perinatal mortality aggregated data suggested that at least part of the mortality decline for amenable conditions was due to better medical care.^ Structure deficiencies were present in 35% of avoidable deaths and process deficiencies were present in 79%. Structure deficiencies remained constant over time. Process deficiencies consisted of diagnosis failures (45.8%) and treatment failures (87.3%), they also remained constant through the years. Party responsibility was as follows: Obstetric (35.4%), pediatric (41.4%), institutional (26.5%), and patient (6.6%). Obstetric responsibility significantly increased during the study period (p $<$.05). Pediatric responsibility declined only for newborns less than 1500 g (p $<$.05). Institutional responsibility remained constant.^ Process deficiencies increased the risk for an avoidable death eightfold (confidence interval 1.7-41.4, p $<$.01) and provider responsibility ninety-fivefold (confidence interval 14.8-612.1, p $<$.001), after adjustment for several confounding variables. Perinatal mortality due to prematurity, barotrauma and nosocomial infection, was highly preventable, but not that due to transpartum asphyxia. Once specific deficiencies in the quality of care have been identified, quality assurance actions should begin. ^

HEAD OF HOUSEHOLD STRUCTURE: ITS INFLUENCE ON THE DIETARY QUALITY OF U.S. HOUSEHOLDS, 1977-78 (UNITED STATES, NATIONWIDE FOOD CONSUMPTION SURVEY)

Using analysis of variance, household data collected in the Spring portion of the 1977-78 Nationwide Food Consumption Survey conducted by the United States Department of Agriculture were analyzed to examine the relationship between household characteristics and dietary quality of the household food supply. Results indicated that head of household structure was a statistically significant variable, with female headed households having higher dietary quality.^ Further analysis indicated that neither race, degree of urbanization, regional location, the education level of the female head, nor her employment status were significant variables in influencing dietary quality. The influence of head of household structure remained significant when these variables were controlled. However, income, household size, and family life cycle stage had statistically significant effects on dietary quality, and when individually controlled, the influence of head of household structure disappeared. ^

International comparison of wait times and quality of care: A pilot study

During the healthcare reform debate in the United States in 2009/2010, many health policy experts expressed a concern that expanding coverage would increase waiting times for patients to obtain care. Many complained that delays in obtaining care in turn would compromise the quality of healthcare in the United States. Using data from The Commonwealth Fund 2010 International Health Policy Survey in Eleven Countries, this study explored the relationship between wait times and quality of care, employing a wait time scale and several quality of care indicators present in the dataset. The impact of wait times on quality was assessed. Increased wait time was expected to reduce quality of care. However, this study found that wait times correlated with better health outcomes for some measures, and had no association with others. Since this is a pilot study and statistical significance was not achieved for any of the correlations, further research is needed to confirm and deepen the findings. However, if future studies confirm this finding, an emphasis on reducing wait times at the expense of other health system level performance variables may be inappropriate. ^

Differences in performance for quality of care indicators for acute myocardial infarction (AMI) across various hospital categories in Texas

The study analyzed Hospital Compare data for Medicare Fee-for-service patients at least 65 years of age to determine whether hospital performance for AMI outcome and processes of care measures differ amongst Texas hospitals with respect to ownership status (for profit vs. not-for-profit), academic status (teaching vs. non-teaching) and geographical setting (rural vs. urban). ^ The study found a statistically significant difference between for-profit and not-for-profit hospitals in four process-of-care measures (aspirin at discharge, P=0.028; ACE or ARB inhibitor for LSVD, P=0.048; Smoking cessation advice: P=0.034; outpatients who got aspirin with 24 hours of arrival in the ED, P=0.044). No significant difference in performance was found between COTH-member teaching and non-teaching hospitals for any of the eight process-of-care measures or the two outcome measures for AMI. The study was unable to compare performance based on geographic setting of hospitals due to lack of sufficient data for rural hospitals. ^ The results of the study suggest that for-profit Texas hospitals might be slightly better than not-for –profit hospitals at providing possible heart attack patients with certain processes of care.^

The role of a nursing home administrator's education in influencing quality of care in US nursing homes

Nursing home literature links poor management practices to poor quality of care and resident outcomes. Since Nursing Home Administrators (NHAs) require an array of skills to perform their role, it is important to explore what makes a NHA effective. This research fills a gap in the literature and provides a possible option to improve the quality of care in nursing homes. Purpose of the study. The study examines whether NHAs with advanced education (defined as a Masters degree or more) are associated with better quality of care in licensed nursing homes (NHs). Design and Methods. Data was derived from the CDC’s 2004 National Nursing Home Survey, which is a representative sample of NHs across the US. A Donabedian- inspired structure-process-outcomes study model was created to explain how education relates to quality of care. Quality of care was defined as onsite oral care, employee influenza vaccination rates and staff recognition programs. Statistical analyses included multivariate logistic regression; covariates included facility-level variables used in similar peer-reviewed research but also included select measures from the Area Resource File to control for county-level factors. Results. Descriptive and analytical analyses confirm that NHAs with a Bachelor’s degree, Associate degree or high school diploma perform less well than NHAs with a Masters degree or more. NHAs with advanced education are more likely to have onsite dental care and recognition programs for staff than NHAs with a Bachelor’s degree (or less). Also NHAs with less than graduate education are more likely to provide off-site dental care. Employee vaccination rates are not impacted by education. Adding certification, tenure or years of experience to a NHA with advanced education gives them an advantage. In fact, certification and experience alone do not have a positive relationship to care indicators; however adding these to advanced education produces a significant result. Implications. This research provides preliminary evidence that advanced education for the NHA is associated with better quality of care. If future research can confirm these findings, there is merit in revisiting the qualifications. Education can be a legitimate option to support quality improvement efforts in US nursing homes. ^

Costs and quality of medication reconciliation practice in primary care clinics

Medication reconciliation, with the aim to resolve medication discrepancy, is one of the Joint Commission patient safety goals. Medication errors and adverse drug events that could result from medication discrepancy affect a large population. At least 1.5 million adverse drug events and $3.5 billion of financial burden yearly associated with medication errors could be prevented by interventions such as medication reconciliation. This research was conducted to answer the following research questions: (1a) What are the frequency range and type of measures used to report outpatient medication discrepancy? (1b) Which effective and efficient strategies for medication reconciliation in the outpatient setting have been reported? (2) What are the costs associated with medication reconciliation practice in primary care clinics? (3) What is the quality of medication reconciliation practice in primary care clinics? (4) Is medication reconciliation practice in primary care clinics cost-effective from the clinic perspective? Study designs used to answer these questions included a systematic review, cost analysis, quality assessments, and cost-effectiveness analysis. Data sources were published articles in the medical literature and data from a prospective workflow study, which included 150 patients and 1,238 medications. The systematic review confirmed that the prevalence of medication discrepancy was high in ambulatory care and higher in primary care settings. Effective strategies for medication reconciliation included the use of pharmacists, letters, a standardized practice approach, and partnership between providers and patients. Our cost analysis showed that costs associated with medication reconciliation practice were not substantially different between primary care clinics using or not using electronic medical records (EMR) ($0.95 per patient per medication in EMR clinics vs. $0.96 per patient per medication in non-EMR clinics, p=0.78). Even though medication reconciliation was frequently practiced (97-98%), the quality of such practice was poor (0-33% of process completeness measured by concordance of medication numbers and 29-33% of accuracy measured by concordance of medication names) and negatively (though not significantly) associated with medication regimen complexity. The incremental cost-effectiveness ratios for concordance of medication number per patient per medication and concordance of medication names per patient per medication were both 0.08, favoring EMR. Future studies including potential cost-savings from medication features of the EMR and potential benefits to minimize severity of harm to patients from medication discrepancy are warranted. ^

Cataract surgery in cancer patients and its impact on quality of life as measured by the National Eye Institute Visual Functioning Questionnaire - 25 (NEI-VFQ-25)

Purpose. The measurement of quality of life has become an important topic in healthcare and in the allocation of limited healthcare resources. Improving the quality of life (QOL) in cancer patients is paramount. Cataract removal and lens implantation appears to improve patient well-being of cancer patients, though a formal measurement has never been published in the US literature. In this current study, National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25), a validated vision quality of life metric, was used to study the change in vision-related quality of life in cancer patients who underwent cataract extraction with intraocular lens implantation. ^ Methods. Under an IRB approved protocol, cancer patients who underwent cataract surgery with intraocular lens implantation (by a single surgeon) from December 2008 to March 2011, and who had completed a pre- and postoperative NEI-VFQ-25 were retrospectively reviewed. Post-operative data was collected at their routine 4-6 week post-op visit. Patients' demographics, cancer history, their pre and postoperative ocular examinations, visual acuities, and NEI-VFQ-25 with twelve components were included in the evaluation. The responses were evaluated using the Student t test, Spearman correlation and Wilcoxon signed rank test. ^ Results. 63 cases of cataract surgery (from 54 patients) from the MD Anderson Cancer Center were included in the study. Cancer patients had a significant improvement in the visual acuity (P<0.0001) postoperatively, along with a significant increase in vision-related quality of life (P<0.0001). Patients also had a statistically significant improvement in ten of the twelve subcategories which are addressed in the NEI-VFQ-25. ^ Conclusions. In our study, cataract extraction and intraocular implantation showed a significant impact on the vision-related quality of life in cancer patients. Although this study includes a small sample size, it serves as a positive pilot study to evaluate and quantify the impact of a surgical intervention on QOL in cancer patients and may help to design a larger study to measure vision related QOL per dollar spent for health care cost in cancer patients.^

Quality of life and functional status in a low -income, multiethnic HIV -positive population

The introduction of new medical treatments in recent years, commonly referred to as highly active antiretroviral therapy, has greatly increased the survival of patients with HIV/AIDS. As patients with HIV/AIDS continue to live longer, other important health-related outcomes, such as quality of life (QOL), should be thoroughly studied. There is also evidence that racial/ethnic minorities are disproportionately affected by HIV/AIDS, but potential health disparities among individuals already infected with HIV/AIDS have not been adequately examined in ethnically diverse populations. The purpose of this dissertation was to: (1) examine the impact of both demographic and behavioral variables on functional status and overall QOL among a population of ethnically diverse and economically disadvantaged HIV/AIDS patients; (2) examine the psychometric properties of a functional status measure—the Household and Leisure Time Activities questionnaire (HLTA); and (3) assess a proximal-distal theoretical framework for QOL using a full structural equation model in a population of patients with HIV/AIDS. Analyses were performed using data collected in the fall of 2000 from the project, Health and Work-Related Quality of Life and Health Risk Behaviors in a Multiethnic HIV-positive Population . Investigators from The University of Texas M.D. Anderson Cancer Center, The University of Texas-Houston Medical School, and The University of Texas School of Public Health conducted this project. The study site was the Thomas Street Clinic (TSC), a comprehensive HIV/AIDS care facility funded by the Harris County Hospital District (HCHD). TSC provides HIV/AIDS care to a diverse population of approximately 4000 medically indigent residents of Harris County. A systematic, consecutive sampling procedure yielded a sample size of 348 patients. Findings suggested that overall QOL, work-role functioning, household functioning, and leisure time functioning were impaired in this patient population. Results from the psychometric evaluation indicated that the HLTA was a reliable and valid measure of household and leisure time functioning status in a low-income multiethnic HIV-positive population. Finally, structural equation modeling of the proximal-distal QOL model suggested that this model was not a viable representation of the relationship between the study variables in this patient population. ^

Comparing the quality of three models of postabortion care in public hospitals in Mexico City

artículo publicado en la revista Int Fam Plan Perspect. 2003 Sep;29(3):112-20

Collection of data on particulate and dissolved soil phosphorus in the Jena Experiment (Main Experiment, time series since 2002)

This data set contains two time series of measurements of dissolved phosphorus (organic, inorganic and total with a biweekly resolution) and dissolved inorganic phosphorus with a seasonal resolution. In addition, data on phosphorus from soil samples measured in 2007 and fractionated by different acid-extrations (Hedley fractions) are provided. All data measured at the main experiment plots of a large grassland biodiversity experiment (the Jena Experiment; see further details below). In the main experiment, 82 grassland plots of 20 x 20 m were established from a pool of 60 species belonging to four functional groups (grasses, legumes, tall and small herbs). In May 2002, varying numbers of plant species from this species pool were sown into the plots to create a gradient of plant species richness (1, 2, 4, 8, 16 and 60 species) and functional richness (1, 2, 3, 4 functional groups). Plots were maintained by bi-annual weeding and mowing. 1. Dissolved phosphorus in soil solution: Suction plates installed on the field site in 10, 20, 30 and 60 cm depth were used to sample soil pore water. Cumulatively extracted soil solution was collected every two weeks from October 2002 to May 2006. The biweekly samples from 2002, 2003 and 2004 were analyzed for dissolved organic phosphorus (DOP), dissolved inorganic phosphorus (PO4P) and dissolved total phosphorus (TDP) by Continuous Flow Analyzer (CFA SAN ++, SKALAR [Breda, The Netherlands]). 2. Seasonal values of dissolved inorganic phosphorus in soil solution were calculated as volume-weighted mean values of the biweekly measurements (spring = March to May, summer = June to August, fall = September to November, winter = December to February). 3. Phosphorus fractions in soil: Five independent soil samples per plot were taken in a depth of 0-15 cm using a soil corer with an inner diameter of 1 cm. The five samples per plot were combined to one composite sample per plot. A four-step sequential P fractionation (Hedley fractions) was applied and concentrations of P fractions in soil were measured photometrically (molybdenum blue-reactive P) with a Continuous Flow Analyzer (Bran&Luebbe, Germany).

Ocean acidification affects growth but not nutritional quality of the seaweed Fucus vesiculosus (Phaeophyceae, Fucales)

Understanding the ecological implications of global climate change requires investigations of not only the direct effects of environmental change on species performance but also indirect effects that arise from altered species interactions. We performed CO2 perturbation experiments to investigate the effects of ocean acidification on the trophic interaction between the brown seaweed Fucus vesiculosus and the herbivorous isopod Idotea baltica. We predicted faster growth of F. vesiculosus at elevated CO2-concentrations and higher carbon content of the algal tissue. We expected that I. baltica has different consumption rates on algae that have been grown at different CO2 levels and that the isopods remove surplus carbon metabolically by enhanced respiration. Surprisingly, growth of F. vesiculosus as well as the C:N-ratio of the algal tissue were reduced at high CO2-levels. The changes in the elemental composition had no effect on the consumption rates and the respiration of the herbivores. An additional experiment showed that consumption of F. vesiculosus by the isopod Idotea emarginata was independent of ocean acidification and temperature. Our results could not reveal any effects of ocean acidification on the per capita strength of the trophic interaction between F. vesiculosus and its consumers. However, reduced growth of the algae at high CO2-concentrations might reduce the capability of the seaweed to compensate losses due to intense herbivory.

Survey on economic assessment of the improvement of the quality of environment: the case of the fight against floods in Cotonou (Benin Living Standard Survey)

This study aims to analyze households' attitude toward flood risk in Cotonou in the sense to identify whether they are willing or not to leave the flood-prone zones. Moreover, the attitudes toward the management of wastes and dirty water are analyzed. The data used in this study were obtained from two sources: the survey implemented during March 2011 on one hundred and fifty randomly selected households living in flood-prone areas of Cotonou, and Benin Living Standard Survey of 2006 (Part relative to Cotonou on 1,586 households). Moreover, climate data were used in this study. Multinomial probability model is used for the econometric analysis of the attitude toward flood risk. While the attitudes toward the management of wastes and dirty water are analyzed through a simple logit. The results show that 55.3% of households agreed to go elsewhere while 44.7% refused [we are better-off here (10.67%), due to the proximity of the activities (19.33), the best way is to build infrastructures that will protect against flood and family house (14.67%)]. The authorities have to rethink an alternative policy to what they have been doing such as building socio-economic houses outside Cotonou and propose to the households that are living the areas prone to inundation. Moreover, access to formal education has to be reinforced.

Markov blanket-based approach for learning multi-dimensional Bayesian network classifiers: An application to predict the European Quality of Life-5 Dimensions (EQ-5D) from the 39-item Parkinson's Disease Questionnaire (PDQ-39)

Multi-dimensional Bayesian network classifiers (MBCs) are probabilistic graphical models recently proposed to deal with multi-dimensional classification problems, where each instance in the data set has to be assigned to more than one class variable. In this paper, we propose a Markov blanket-based approach for learning MBCs from data. Basically, it consists of determining the Markov blanket around each class variable using the HITON algorithm, then specifying the directionality over the MBC subgraphs. Our approach is applied to the prediction problem of the European Quality of Life-5 Dimensions (EQ-5D) from the 39-item Parkinson’s Disease Questionnaire (PDQ-39) in order to estimate the health-related quality of life of Parkinson’s patients. Fivefold cross-validation experiments were carried out on randomly generated synthetic data sets, Yeast data set, as well as on a real-world Parkinson’s disease data set containing 488 patients. The experimental study, including comparison with additional Bayesian network-based approaches, back propagation for multi-label learning, multi-label k-nearest neighbor, multinomial logistic regression, ordinary least squares, and censored least absolute deviations, shows encouraging results in terms of predictive accuracy as well as the identification of dependence relationships among class and feature variables.

PROFILE AND THE QUALITY OF LIFE OF LOGGERS

RESUMO – Objetivou-se com este estudo caracterizar o perfil e avaliar o nível de satisfação que reflete na qualidade de vida no trabalho (QVT) de trabalhadores da colheita de madeira de duas contratadas (C1 e C2), por duas grandes empresas do setor florestal, sendo uma do segmento de papel e celulose (PC) e, a outra, do segmento de carvão vegetal (CV). A avaliação ocorreu a partir da percepção dos trabalhadores das contratadas em questão, utilizando um modelo pré-concebido que contempla 11 blocos ou dimensões referentes a variáveis intervenientes e definidores da QVT, englobando 48 trabalhadores em três categorias funcionais: operador de motosserra (7 trabalhadores da C1 PC e 10 da C2 CV), ajudante de motosserrista (7 trabalhadores da C1 PC e 8 da C2 CV) e operador de carregador florestal (11 trabalhadores da C1 PC e 5 da C2 CV). Os dados referentes às variáveis intervenientes na QVT foram obtidos a partir de escala fechada do tipo Likert, com os escores variando de 1 a 7, em que 1 correspondeu ao nível "bastante insatisfeito" e 7, ao nível "bastante satisfeito". O perfil dos trabalhadores é de pessoa jovem, baixo nível de escolaridade e pouco tempo de serviço na empresa. Quanto ao nível de satisfação no trabalho, constatou-se que os trabalhadores da C1 PC se encontravam "satisfeitos" e os da C2 CV, "mediamente satisfeitos" com o trabalho e as condições proporcionadas pelas respectivas empresas, apesar de estatisticamente não ter sido detectada diferença entre os valores médios encontrados nas duas situações, pelo teste de Mediana (P>0,01). Os fatores que mais contribuíram para esses resultados favoráveis foram os benefícios extras oferecidos pelas prestadoras de serviços, as condições de segurança no trabalho e o contentamento com o emprego formal. ABSTRACT – The objective of this study was to characterize profile and satisfaction level, which reflects the quality of life (QOL) of forest workers of two contracts for harvest activities, one in the pulp and paper industry (PI) and another in charcoal industry (CI). The evaluation of the satisfaction indexes was carried out according to the workers perception by using a model including 11 parameters to reflect these workers QOL. The group study of 48 workers encompassed three functional categories: chainsaw operators (7 from C1 and 10 from C2), chainsaw operator's assistant (7 from C1 and 8 from C2), and log loader operators (11 from C1 and 5 from C2). Data regarding the factors involved in QOL were collected from a closed, Likert-type scale with scores ranging from 1-7, in which level 1 corresponded to "very dissatisfied" and level 7 to "very satisfied". The general profile of the group shows that most of them are young, with low level of education and employed in the companies for a short time. Overall, the employees of contractors of the paper and pulp industry are "satisfied" and those working for the charcoal company are only "moderately satisfied" with the work and policies offered by the respective companies, although no significant statistical difference was detected between the two groups, for the median test (P> 0.01). The main reasons behind these results are the general beneficts offered by the companies, the safety measurements and the overall satisfaction for been employed.

Quality of Service (QoS) in MPLS networks

Telecommunications networks have been always expanding and thanks to it, new services have appeared. The old mechanisms for carrying packets have become obsolete due to the new service requirements, which have begun working in real time. Real time traffic requires strict service guarantees. When this traffic is sent through the network, enough resources must be given in order to avoid delays and information losses. When browsing through the Internet and requesting web pages, data must be sent from a server to the user. If during the transmission there is any packet drop, the packet is sent again. For the end user, it does not matter if the webpage loads in one or two seconds more. But if the user is maintaining a conversation with a VoIP program, such as Skype, one or two seconds of delay in the conversation may be catastrophic, and none of them can understand the other. In order to provide support for this new services, the networks have to evolve. For this purpose MPLS and QoS were developed. MPLS is a packet carrying mechanism used in high performance telecommunication networks which directs and carries data using pre-established paths. Now, packets are forwarded on the basis of labels, making this process faster than routing the packets with the IP addresses. MPLS also supports Traffic Engineering (TE). This refers to the process of selecting the best paths for data traffic in order to balance the traffic load between the different links. In a network with multiple paths, routing algorithms calculate the shortest one, and most of the times all traffic is directed through it, causing overload and packet drops, without distributing the packets in the other paths that the network offers and do not have any traffic. But this is not enough in order to provide the real time traffic the guarantees it needs. In fact, those mechanisms improve the network, but they do not make changes in how the traffic is treated. That is why Quality of Service (QoS) was developed. Quality of service is the ability to provide different priority to different applications, users, or data flows, or to guarantee a certain level of performance to a data flow. Traffic is distributed into different classes and each of them is treated differently, according to its Service Level Agreement (SLA). Traffic with the highest priority will have the preference over lower classes, but this does not mean it will monopolize all the resources. In order to achieve this goal, a set policies are defined to control and alter how the traffic flows. Possibilities are endless, and it depends in how the network must be structured. By using those mechanisms it is possible to provide the necessary guarantees to the real-time traffic, distributing it between categories inside the network and offering the best service for both real time data and non real time data. Las Redes de Telecomunicaciones siempre han estado en expansión y han propiciado la aparición de nuevos servicios. Los viejos mecanismos para transportar paquetes se han quedado obsoletos debido a las exigencias de los nuevos servicios, que han comenzado a operar en tiempo real. El tráfico en tiempo real requiere de unas estrictas garantías de servicio. Cuando este tráfico se envía a través de la red, necesita disponer de suficientes recursos para evitar retrasos y pérdidas de información. Cuando se navega por la red y se solicitan páginas web, los datos viajan desde un servidor hasta el usuario. Si durante la transmisión se pierde algún paquete, éste se vuelve a mandar de nuevo. Para el usuario final, no importa si la página tarda uno o dos segundos más en cargar. Ahora bien, si el usuario está manteniendo una conversación usando algún programa de VoIP (como por ejemplo Skype) uno o dos segundos de retardo en la conversación podrían ser catastróficos, y ninguno de los interlocutores sería capaz de entender al otro. Para poder dar soporte a estos nuevos servicios, las redes deben evolucionar. Para este propósito se han concebido MPLS y QoS MPLS es un mecanismo de transporte de paquetes que se usa en redes de telecomunicaciones de alto rendimiento que dirige y transporta los datos de acuerdo a caminos preestablecidos. Ahora los paquetes se encaminan en función de unas etiquetas, lo cual hace que sea mucho más rápido que encaminar los paquetes usando las direcciones IP. MPLS también soporta Ingeniería de Tráfico (TE). Consiste en seleccionar los mejores caminos para el tráfico de datos con el objetivo de balancear la carga entre los diferentes enlaces. En una red con múltiples caminos, los algoritmos de enrutamiento actuales calculan el camino más corto, y muchas veces el tráfico se dirige sólo por éste, saturando el canal, mientras que otras rutas se quedan completamente desocupadas. Ahora bien, esto no es suficiente para ofrecer al tráfico en tiempo real las garantías que necesita. De hecho, estos mecanismos mejoran la red, pero no realizan cambios a la hora de tratar el tráfico. Por esto es por lo que se ha desarrollado el concepto de Calidad de Servicio (QoS). La calidad de servicio es la capacidad para ofrecer diferentes prioridades a las diferentes aplicaciones, usuarios o flujos de datos, y para garantizar un cierto nivel de rendimiento en un flujo de datos. El tráfico se distribuye en diferentes clases y cada una de ellas se trata de forma diferente, de acuerdo a las especificaciones que se indiquen en su Contrato de Tráfico (SLA). EL tráfico con mayor prioridad tendrá preferencia sobre el resto, pero esto no significa que acapare la totalidad de los recursos. Para poder alcanzar estos objetivos se definen una serie de políticas para controlar y alterar el comportamiento del tráfico. Las posibilidades son inmensas dependiendo de cómo se quiera estructurar la red. Usando estos mecanismos se pueden proporcionar las garantías necesarias al tráfico en tiempo real, distribuyéndolo en categorías dentro de la red y ofreciendo el mejor servicio posible tanto a los datos en tiempo real como a los que no lo son.