Impacto de la prestación de servicios de salud bajo el modelo de red en el municipio de Sogamoso

El presente estudio es de tipo analítico, cohorte retrospectiva, tiene como objeto estudiar un modelo de prestación de servicios de salud bajo el concepto de red integrada, conformada por las clínicas privadas de segundo y tercer nivel de complejidad del municipio de Sogamoso (Boyacá). Se analizó el período comprendido entre los años 2012 a 2014, donde se puede evidenciar la implementación y puesta en marcha del modelo. En el mes de agosto del año 2012, la estrategia de asociatividad la adelantaron las tres instituciones de manera libre y autónoma, utilizando como guía la metodología propuesta por la Cepal en el año 2010; las diferencias entre esta metodología y el modelo utilizado se deben a las particularidades de las clínicas y del contexto en el que se desarrolló. Este modelo de atención surgió de la necesidad de prestar los servicios de salud ofertados por las clínicas, acorde con su capacidad instalada, al total de la población de la Nueva EPS en Sogamoso, que en ese momento coyuntural no se estaba cumpliendo en el municipio, y ninguna de las instituciones tenía la infraestructura individual para atender a toda su población. El resultado de la asociación de las tres clínicas se logró gracias a un grado de confianza previo entre los directivos de las instituciones y posterior a varias reuniones, en las que se tomó la determinación de trabajar con el modelo de Unión Temporal, ya que no son una persona jurídica diferente a las que la conforman Se demuestra el impacto de este modelo asociativo de cada una de las organizaciones que la componen evaluando cuatro ámbitos como la capacidad de aprendizaje, capacidad de gestión estratégica, economía de escala y poder de negociación y externalidades. Para la recolección de la información se utilizaron las bases de datos de las instituciones hospitalarias con la información de los indicadores de oportunidad, así como el incremento de la facturación y del recaudo antes y después de la formación de la Unión Temporal; adicionalmente se realizaron encuestas a los directores de las clínicas como fuente de información para desarrollo de nuevos productos, reducción de costos, ampliación de la oferta hospitalaria, establecimientos de alianza, puesta en marcha de servicios comunes y apertura de nuevos mercados. Sumado a lo anterior, se realizó una encuesta adicional a los usuarios del nuevo producto desarrollado. Como resultado de este estudio se encuentra beneficio en todos los ámbitos evaluados para las instituciones que interactúan bajo este modelo y se espera que obtengan los mismos beneficios que los demás actores participantes en él, como las EAPB, los cuales no hacen parte del presente estudio. En Colombia no se observa la existencia de un modelo similar en sistema de salud, a pesar del leve intento de la Ley 1438 del 2011 por iniciar la conformación de redes; por esta razón se puede decir que este estudio marca un derrotero para que las organizaciones de salud tengan un modelo de articulación ante la falta de desarrollos de esquemas de red y por tratarse de un modelo con ausencia de reglamentación.

The effects of mass loading the ossicles with a floating mass transducer on middle ear transfer function

Hypothesis: The aim of this study was to measure the mass loading effect of an active middle-ear implant (the Vibrant Soundbridge) in cadaver temporal bones. Background: Implantable middle ear hearing devices such as Vibrant Soundbridge have been used as an alternative to conventional hearing aids for the rehabilitation of sensorineural hearing loss. Other than the obvious disadvantage of requiring implantation middle ear surgery, it also applies a direct weight on the ossicular chain which, in turn, may have an impact on residual hearing. Previous studies have shown that applying a mass directly on the ossicular chain has a damping effect on its response to sound. However, little has been done to investigate the magnitude and the frequency characteristics of the mass loading effect in devices such as the Vibrant Soundbridge. Methods: Five fresh cadaver temporal bones were used. The stapes displacement was measured using laser Doppler vibrometry before and after the placement of a Vibrant Sound-bridge floating mass transducer. The effects of mass and attachment site were compared with the unloaded response. Measurements were obtained at frequencies between 0.1 and 10 kHz and at acoustic input levels of 100 dB sound pressure level. Each temporal bone acted as its own control. Results: Placement of the floating mass transducer caused a reduction of the stapes displacement. There were variations between the bones. The change of the stapes displacement varied from 0 dB to 28 dB. The effect was more prominent at frequencies above 1,000 Hz. Placing the floating mass transducer close to the incudostapedial joint reduced the mass loading effect. Conclusion: The floating mass transducer produces a measurable reduction of the stapes displacement in the temporal bone model. The effect is more prominent at high frequencies.

A compositional framework for hardware/software co-design

We describe a compositional framework, together with its supporting toolset, for hardware/software co-design. Our framework is an integration of a formal approach within a traditional design flow. The formal approach is based on Interval Temporal Logic and its executable subset, Tempura. Refinement is the key element in our framework because it will derive from a single formal specification of the system the software and hardware parts of the implementation, while preserving all properties of the system specification. During refinement simulation is used to choose the appropriate refinement rules, which are applied automatically in the HOL system. The framework is illustrated with two case studies. The work presented is part of a UK collaborative research project between the Software Technology Research Laboratory at the De Montfort University and the Oxford University Computing Laboratory.

Modeling building semantics: providing feedback and sustainability

Even minor changes in user activity can bring about significant energy savings within built space. Many building performance assessment methods have been developed, however these often disregard the impact of user behavior (i.e. the social, cultural and organizational aspects of the building). Building users currently have limited means of determining how sustainable they are, in context of the specific building structure and/or when compared to other users performing similar activities, it is therefore easy for users to dismiss their energy use. To support sustainability, buildings must be able to monitor energy use, identify areas of potential change in the context of user activity and provide contextually relevant information to facilitate persuasion management. If the building is able to provide users with detailed information about how specific user activity that is wasteful, this should provide considerable motivation to implement positive change. This paper proposes using a dynamic and temporal semantic model, to populate information within a model of persuasion, to manage user change. By semantically mapping a building, and linking this to persuasion management we suggest that: i) building energy use can be monitored and analyzed over time; ii) persuasive management can be facilitated to move user activity towards sustainability.

Heuristic optimization of the p-median problem and population re-distribution

This thesis contributes to the heuristic optimization of the p-median problem and Swedish population redistribution.   The p-median model is the most representative model in the location analysis. When facilities are located to a population geographically distributed in Q demand points, the p-median model systematically considers all the demand points such that each demand point will have an effect on the decision of the location. However, a series of questions arise. How do we measure the distances? Does the number of facilities to be located have a strong impact on the result? What scale of the network is suitable? How good is our solution? We have scrutinized a lot of issues like those. The reason why we are interested in those questions is that there are a lot of uncertainties in the solutions. We cannot guarantee our solution is good enough for making decisions. The technique of heuristic optimization is formulated in the thesis.   Swedish population redistribution is examined by a spatio-temporal covariance model. A descriptive analysis is not always enough to describe the moving effects from the neighbouring population. A correlation or a covariance analysis is more explicit to show the tendencies. Similarly, the optimization technique of the parameter estimation is required and is executed in the frame of statistical modeling. 

How do neighbouring populations affect local population change over time?

This study covers a period when society changed from a pre-industrial agricultural society to a post-industrial service-producing society. Parallel with this social transformation, major population changes took place. In this study, we analyse how local population changes are affected by neighbouring populations. To do so we use the last 200 years of local population change that redistributed population in Sweden. We use literature to identify several different processes and spatial dependencies in the redistribution between a parish and its surrounding parishes. The analysis is based on a unique unchanged historical parish division, and we use an index of local spatial correlation to describe different kinds of spatial dependencies that have influenced the redistribution of the population. To control inherent time dependencies, we introduce a non-separable spatial temporal correlation model into the analysis of population redistribution. Hereby, several different spatial dependencies can be observed simultaneously over time. The main conclusions are that while local population changes have been highly dependent on the neighbouring populations in the 19th century, this spatial dependence have become insignificant already when two parishes is separated by 5 kilometres in the late 20th century. Another conclusion is that the time dependency in the population change is higher when the population redistribution is weak, as it currently is and as it was during the 19th century until the start of industrial revolution.

Implementação de bancos de dados temporais com versionamento de esquemas: um estudo comparativo

Nas aplicações do mundo real, os dados mudam com o passar do tempo. Devido à característica dinâmica das aplicações, o esquema conceitual também pode mudar para se adaptar às mudanças que freqüentemente ocorrem na realidade. Para representar esta evolução, uma nova versão do esquema é definida e os dados armazenados são adaptados à nova versão. Entretanto, existem aplicações que precisam acessar também o esquema sob os diversos aspectos de suas mudanças, requerendo o uso de versionamento de esquemas. Durante a evolução do esquema, o versionamento preserva todas as versões deste esquema e seus dados associados, possibilitando a recuperação dos dados através da versão com a qual foram definidos. Ultimamente muitas pesquisas têm sido realizadas envolvendo as áreas de versionamento de esquemas e bancos de dados temporais. Estes bancos de dados provêm suporte ao versionamento de esquemas, pois permitem armazenar e recuperar todos os estados dos dados, registrando sua evolução ao longo do tempo. Apesar de muitos esforços, ainda não existem SGBDs temporais comercialmente disponíveis. A utilização de um modelo de dados temporal para a especificação de uma aplicação não implica, necessariamente, na utilização de um SGBD específico para o modelo. Bancos de dados convencionais podem ser utilizados desde que exista um mapeamento adequado entre o modelo temporal e o SGBD utilizado. Este trabalho apresenta uma abordagem para a implementação de um banco de dados temporal permitindo o versionamento de esquemas, usando um banco de dados relacional, tendo como base o modelo temporal TRM (Temporal Relational Model). Como forma de ilustrar apresenta-se um exemplo de implementação utilizando o SGBD DB2. O principal objetivo é avaliar diferentes técnicas de implementar e gerenciar o versionamento de esquemas em bancos de dados temporais. Para atingir esse objetivo, um protótipo foi desenvolvido para automatizar os mapeamentos do TRM para o DB2 e gerenciar o versionamento de esquemas e dados. Duas experiências de implementação foram realizadas utilizando formas diferentes de armazenar os dados - um repositório e vários repositórios - com o objetivo de comparar os resultados obtidos, considerando um determinado volume de dados e alterações. Um estudo de caso também é apresentado para validar as implementações realizadas.

Projeto de um DB2 extender para suporte aos conceitos de tempo e versão

A utilização de versões permite o armazenamento de diferentes alternativas de projeto no desenvolvimento de uma aplicação. Entretanto, nem todo o histórico das alterações aplicadas sobre os dados é registrado. Modificações importantes podem ser realizadas e os valores anteriores são perdidos. O histórico completo somente é acessível através da junção de versões com um modelo temporal. Os conceitos de tempo e de versão aplicados em conjunto possibilitam a modelagem de aplicações complexas. Uma extensão que implemente simultaneamente estes dois conceitos em um banco de dados comercial não está disponível. O Modelo Temporal de Versões (TVM – Temporal Version Model) fornece a base para esta funcionalidade. O objetivo deste trabalho é projetar um extender para oferecer suporte aos conceitos de tempo e versão no sistema DB2, utilizando como base o TVM. A extensão engloba o mapeamento da hierarquia do TVM; a criação de tabelas administrativas; procedimentos para especificação das classes, atributos e relacionamentos; a definição de gatilhos e restrições para a manipulação dos dados diretamente nas tabelas criadas; e a especificação de procedimentos e UDFs para controle de versões e valores temporais e de outras UDFs que permitem consultas envolvendo os dois conceitos. Apesar do SGBD não ser totalmente orientado a objetos, como é definido no modelo utilizado (TVM), oferece mecanismos que permitem o mapeamento para um modelo objetorelacional. Através da utilização desta extensão, a união de tempo e de versões pode ser utilizada em aplicações reais.

Semântica formal para TVQL

Modelos de bancos de dados têm sido progressivamente estendidos a fim de melhor capturar necessidades específicas de aplicações. Bancos de dados versionados, por exemplo, provêm suporte a versões alternativas de objetos. Bancos de dados temporais, por sua vez, permitem armazenar todos os estados de uma aplicação, registrando sua evolução com o passar do tempo. Tais extensões sobre os modelos de dados se refletem nas respectivas linguagens de consulta, normalmente sob a forma de extensões a linguagens conhecidas, tais como SQL ou OQL. O modelo de banco de dados TVM (Temporal Versions Model ), definido sobre o modelo de banco de dados orientado a objetos, suporta simultaneamente versões alternativas e o registro de alterações de objetos ao longo do tempo. A linguagem de consulta TVQL (Temporal Versioned Query Language), definida a partir da linguagem de consulta SQL, permite recuperar informações do modelo de dados TVM. As construções introduzidas em TVQL têm como objetivo tornar simples a consulta do banco de dados em diversos pontos da linha temporal. Apesar das vantagens da utilização da linguagem TVQL para resgatar dados temporais do modelo TVM, existem algumas limitações importantes para seu aprimoramento. Uma delas é a alta complexidade do modelo TVM, proveniente da integração de conceitos variados como estados alternativos e rótulos temporais. Outro ponto é que, até o presente momento, não existe um interpretador para TVQL, impedindo uma experiência prática de programação de consultas. O objetivo principal deste trabalho é o desenvolvimento de uma especificação formal para a linguagem TVQL, tornando possível um estudo consistente de suas construções. Adicionalmente, uma especificação formal serve como documentação para futuras implementações de interpretadores. Neste trabalho foi desenvolvido um protótipo de avaliador de consultas e verificador de tipos para um núcleo funcional da linguagem TVQL, possibilitando também uma experimentação prática sobre os modelos propostos.

Efeito agudo de uma sessão de exercícios aeróbios e resistidos na pressão arterial de indivíduos normotensos e hipertensos pertencentes ao Programa de Atividade Física na UBS e PSF do município de Rio Claro-SP

A hipertensão arterial (HA) é fator de risco para o desenvolvimento de doenças cardiovasculares, uma forma de prevenção seria a adoção de um estilo de vida mais ativo.O estudo tem como objetivo verificar se uma sessão de exercícios resistidos e aeróbios provoca efeito hipotensivo em indivíduos normotensos e hipertensos sendo a P.A aferida antes e depois dos exercícios. Participaram do estudo 29 indivíduos, normo e hipertensos, com idade média de 54,96 anos ( ± 9,56 ), todos participantes do projeto de atividade física para diabéticos e hipertensos, desenvolvido pelo NAFES da UNESP – Rio Claro. A aula constituiu-se de aquecimento e alongamento (10 min), parte principal (40 min) dividida por: Caminhada (10 min), exercícios resistidos de membro superior utilizando halteres de um quilo (10 min), caminhada (10 min) e exercícios resistidos de membros inferiores com peso corporal (10 min), finalizando com volta calma(10 min). A Pressão Arterial foi aferida através de aparelho digital de pulso Fuzzy LOGIC, Model 3001, BioLand em repouso(M1), ao termino(M2), 30 minutos pós-exercícios(M3) e 4 horas após o termino dos exercícios(M4). Os dados foram analisados por meio do ANOVA para análises repetidas, através do programa Statistic 7.0 e significância de p<0,05. A analise estatística mostrou que na pressão sistólica não houve diferença significante do M1(137,6 ±17,1mmHg) para o M3(133,9 ±18,8mmHg) enquanto que na pressão diastólica observou-se diferença significativa do M1(84,7 ±9,3mmHg) para o M4(80,7 ±11.2mmHg). Conclusão: Houve efeito hipotensor após exercícios apenas na pressão diastólica, já na pressão sistólica não ocorreu mudança significativa embora todos os valores pós exercícios tenham diminuído, tanot na sistólica quanto na diastólica.

Adolescent Pregnancy Prevention in San Jose, Costa Rica : Assessment of an Educational Intervention

This thesis explores adolescent pregnancy in San Jose, Costa Rica and examines a school-based pregnancy prevention intervention. The relationships between school, gender and risk of adolescent pregnancy are also analyzed, and recommendations are made for effective pregnancy prevention programming. The Purral region of Guadalupe on the outskirts of San Jose, Costa Rica, suffers a higher rate of adolescent pregnancy compared to the rest of the country. In response to this problem, the International Health Central American Institute (IHCAI) implemented a sexual health education program in two local secondary schools in 2006. Very little information about the program is available. It is known that the program was initially evaluated through assessments of the participants’ knowledge before and after the educational sessions. There was no evaluation of the youth attitudes or behaviors, adolescent pregnancies, or long-term impact. The author worked with IHCAI in San Jose, Costa Rica to perform an assessment of the longer term effects of this sexual health education program. They developed a questionnaire to evaluate the knowledge, attitudes, and behaviors surrounding sexual health of youth in the Purral community. Researchers at IHCAI later used this survey to collect data from adolescents who had participated in the educational intervention and those who had not. This thesis analyzes the data collected by IHCAI to assess the effectiveness of the - 2 - educational intervention and the influence of other factors on the knowledge, attitudes, and behaviors of adolescents in the Purral region. The thesis begins with an overview of adolescent pregnancy, Costa Rica and the Purral region, and a description of the education intervention implemented by IHCAI. The research goal, logic model, and methods are then described. The results are reported, and the thesis then concludes with discussion of the results as well as study limitations and recommendations for future research and intervention. This thesis will be used to guide IHCAI’s continuation and expansion of adolescent pregnancy prevention programming.

Can accreditation work as a tool for quality improvement in public health? A critical review

Public health departments play an important role in promoting and preserving the health of communities. The lack of a system to ensure their quality and accountability led to the development of a national voluntary accreditation program by Public Health Accreditation Board (PHAB). The concept that accreditation will lead to quality improvement in public health which will ultimately lead to healthy communities seems intuitive but lacks a robust body of evidence. A critical review of literature was conducted to explore if accreditation can lead to quality improvement in public health. The articles were selected from publically available databases using a specific set of criteria for inclusion, exclusion, and appraisal. To understand the relationship between accreditation and quality improvement, the potential strengths and limitations of accreditation process were evaluated. Recommendations for best practices are suggested so that public health accreditation can yield maximum benefits. A logic model framework to help depict the impact of accreditation on various levels of public health outcomes is also discussed in this thesis. The literature review shows that existing accreditation programs in other industries show limited but encouraging evidence that accreditation will improve quality and strengthen the delivery of public health services. While progress in introducing accreditation in public health can be informed by other accredited industries, the public health field has its own set of challenges. Providing incentives, creating financing strategies, and having a strong leadership will allow greater access to accreditation by all public health departments. The suggested recommendations include that continuous evaluation, public participation, systems approach, clear vision, and dynamic standards should become hallmarks of the accreditation process. Understanding the link between accreditation, quality improvement, and health outcomes will influence the successful adoption and implementation of the public health accreditation program. This review of literature suggests that accreditation is an important step in improving the quality of public health departments and in ultimately improving the health of communities. However, accreditation should be considered in an integrated system of tools and approaches to improve the public health practice. Hence, it is a means to an end - not an end unto itself.^

Recommendations for dementia caregiver stress interventions based on Intervention Mapping guidelines

Stress can affect a person's psychological and physical health and cause a variety of conditions including depression, immune system changes, and hypertension (Alzheimer's Association, 2010; Aschbacher et al., 2009; Fredman et al., 2010; Long et al., 2004; Mills et al., 2009; von Känel et al., 2008). The severity and consequences of these conditions can vary based on the duration, amount, and sources of stress experienced by the individual (Black & Hyer, 2010; Coen et al., 1997; Conde-Sala et al., 2010; Pinquart & Sörensen, 2007). Caregivers of people with dementia have an elevated risk for stress and its related health problems because they experience more negative interactions with, and provide more emotional support for, their care recipients than other caregivers. ^ This paper uses a systematic program planning process of Intervention Mapping to organize evidence from literature, qualitative research and theory to develop recommendations for a theory- and evidence-based intervention to improve outcomes for caregivers of people with dementia. A needs assessment was conducted to identify specific dementia caregiver stress influences and a logic model of dementia caregiver stress was developed using the PRECEDE Model. Necessary behavior and environmental outcomes are identified for dementia caregiver stress reduction and performance objectives for each were combined with selected determinants to produce change objectives. Planning matrices were then designed to inform effective theory-based methods and practical applications for recommended intervention delivery. Recommendations for program components, their scope and sequence, the completed program materials, and the program protocols are delineated along with ways to insure that the program is adopted and implemented after it is shown to be effective.^

Factors associated with contraception use among postpartum or parenting Latina adolescents: A systematic review

Despite advances in effective and long-acting contraceptive methods and the introduction into health care that an initial unplanned pregnancy allows, repeat unplanned pregnancy continues to affect Hispanic adolescents at a rate higher than that of non-Hispanic whites. The current study was undertaken to identify and categorize factors associated with uptake of long acting contraception (implant or intrauterine devices) or consistent use of highly effective methods (injectable DMPA, ring, patch, or pills), among Hispanic/Latina teens who have previously given birth. ^ I searched Ovid Medline, Pubmed, CINAHL, PsychINFO, POPLINE and Scopus, and reference lists for studies in English, ≥1980, of original data from the United States on factors related to initiation, maintenance, or discontinuation of contraceptive methods in postpartum or parenting adolescent females. I then identified articles that specified the inclusion of Hispanics/Latinas in the study population and either reported findings specific to race/ethnicity or used race/ethnicity as an independent variable in analyses of contributing factors. I then extracted data for each study and categorized independent variables as predisposing, enabling, or reinforcing following the PRECEDE model.1 Factors found to be associated with contraception use or non-use were combined to create a logic model of risk. ^ Of 9 eligible studies, one solely addressed initiation; one, initiation and maintenance; two, initiation and discontinuation; three, maintenance; and two, maintenance and discontinuation. There was some overlap in the studies' assessments of maintenance and discontinuation and the author(s) often did not distinguish between the two. Nearly all (k=7) were prospective observational studies with convenience samples and bivariate analyses (k=6). One study was initially a quasi-experimental design but became a prospective cohort due to extremely high attrition. Sociodemographic characteristics and predisposing factors were studied frequently, as were reinforcing factors; enabling factors were discussed infrequently and only in studies involving focus groups or interviews. Due to a paucity of research, a consensus of factors found consistently to influence the contraception behavior of postpartum Latina teens could not be established for the overall population nor for cultural subgroups. Future research is needed that focuses on postpartum/parenting Latina teens, with subgroup identification and differentiation, to determine the prevalent and pertinent predisposing, enabling, and reinforcing factors related to effective contraception initiation and maintenance.^

Savitri y Orfeo : La argumentación en la lógica india y en la retórica clásica

Los mitos de Savitri (Mahabharata 3.293-299) y Orfeo (Ovidio. Metamorfosis 10.1-85), pertenecientes al ámbito cultural indoeur opeo, presentan algunos puntos en común: narran la historia del amante que rescata a su ser amado de la muerte, y combinan el encuentro con los dioses de la muerte y el discurso mediante el poder de la palabra. En esta propuesta, se analizan los discursos de los protagonistas a partir de las convenciones propias de cada contexto de enunciación. Para el caso indio, se sigue el modelo lógico de la escuela Nyaya; para el greco-latino, el de la retórica clásica. De este modo, sobre la base de la estructura argumentativa del silogismo aristotélico, se plantean dos variaciones, respectivamente, el silogismo hindú y el silogismo retórico. Se trata de dos aproximaciones argumentativas con métodos distintos pero con un mismo fin: (con)vencer al oponente