Editorial
Sistema nacional de residencias médicas:
una tarea pendiente
Luis Carlos Ortiz Monsalve Director Proyectos especiales
Asociación Colombiana de Facultades de Medicina (Ascofame)
Bogotá, D.C., Colombia [email protected]
La expedición de la Ley 1917 de 2018, por medio de la cual se reglamenta el Sistema de Residencias Médicas en Colombia, su mecanismo de financiación y se dictan otras disposiciones, generó grandes expectativas con relación al mejoramiento de las condiciones de formación de los residentes y la superación de las dificultades históricas que ha enfrentado la formación de médicos especialistas en nuestro país. Esta ley tiene origen legislativo y su propósito inicial era establecer la forma de vin-culación, remuneración y las condiciones financieras de matrícula de los residentes. Es un tema de la mayor importancia. La evolución de los sistemas de salud y de la medicina está marcada por el crecimiento exponencial del conocimiento y de las tecnologías y por el empoderamiento de los pacientes. Esto genera la necesidad cada vez mayor de médicos que profundicen y se especialicen en áreas específicas del conocimiento para poner esos avances al servicio de la salud de la población. Es de anotar que en gran parte de países de Europa y Norteamérica se exige como requisito para ejercer la medicina que el profesional haya cursado una especiali-zación médica.
Esta Ley también tiene un impacto significativo en más de 5.300 médicos que de manera permanente están cursando alguna especialización médico-quirúrgica, así como en las Instituciones de Educación Superior (IES) que ofrecen los 545 progra-mas autorizados en Colombia y las 400 Instituciones Prestadoras de Servicios de Salud (IPS) donde se realizan las prácticas formativas.
La Ley 1917 de 2018 introdujo un avance importante al crear la figura especial de residente, distinta a la de estudiante y de trabajador: son médicos “con autoriza-ción vigente para ejercer su profesión en Colombia… que cursan especializaciones médico quirúrgicas en programas académicos… [que] podrán ejercer plenamente las competencias propias de la profesión o especialización para las cuales estén previamente autorizados, así como aquellas asociadas a la delegación progresiva de responsabilidades que corresponda a su nivel de formación” (art. 4).
Esta definición deja sin fundamento los argumentos que desconocían la legiti-midad de la participación del residente, dada su condición de estudiante, en los servicios de salud o solo la relacionaban con mayores costos, afectaciones a la calidad en la prestación de servicios y una causa de glosas a las facturas de las IPS. Los pacientes tendrán ahora la confianza de que los atiende un médico, no un mero estudiante, y habrá más claridad en los temas de responsabilidad médica de los equipos de salud.
La citada ley también dio un paso adelante al definir la obligatoriedad de remunerar a los residentes, con tres salarios mínimos mensuales, a través del contrato especial de práctica formativa (art. 5), y al establecer las fuentes para financiar la remunera-ción de los residentes de primeras especializaciones (art. 8). Este es un avance clave para superar las limitaciones de cobertura del programa de becas crédito creado en la Ley 100 de 1993.
DOI: https://doi.org/10.18270/rsb.v9i2.2798
How to cite:
Queda por conocer cómo se va a financiar el pago de los cerca de 500 residentes de segundas y terceras especializaciones, así como sus posibles efectos sobre la oferta de estos programas, y si habrá garan-tías frente a eventuales demoras o incumplimientos en el flujo de los recursos para pagar oportunamente a los residentes, de tal forma que no se afecte la normalidad de los procesos académicos y asistenciales. Ahora bien, ¿cuál es el alcance de Ley 1917 de 2018 frente a la reduc-ción del valor de las matrículas de los programas de residencia? La nor-ma contiene dos disposiciones que pueden incidir en este propósito. La primera es la prohibición del cobro en dinero de las contrapres-taciones que piden las IPS por la rotación de los residentes en sus servicios (art. 12). Sin duda es una medida con buen propósito, pero deja abierta la posibilidad de negociar contraprestaciones en especies, sin establecer límites en los montos cobrados ni orientaciones para su destinación a los procesos docentes, por lo cual es poco probable que termine reduciendo el valor de las matrículas.
La otra disposición busca limitar el valor de la matrícula de los pro-gramas de residencia a los costos administrativos y operativos en que incurran la IES para su desarrollo (art. 12). Sin entrar a discutir si esta disposición afecta o no la autonomía universitaria, su aplicación tam-poco garantiza la reducción del valor de las matrículas, hasta tanto no se haga claridad sobre los costos reales de cada programa. Incluso se ha planteado que, en algunos programas, ese valor podría ser superior si no se racionaliza el cobro de las contraprestaciones o por efecto de los costos para su acreditación en alta calidad.
La vigilancia de esta disposición le corresponde al Ministerio de Edu-cación Nacional y a la Supersalud (art. 12), pero aún no hay claridad sobre la definición de los costos ni cuáles serán los instrumentos para su control y verificación. Esta situación ya ha complejizado y ralentiza-do la negociación de convenios ralentiza-docencia servicio entre IES e IPS, ante la duda de si las contraprestaciones en especies que se acuerden serán aceptadas como parte de los costos para fijar el valor de las matrículas. Así las cosas, los efectos de estas dos medidas dependerán en gran medida de su reglamentación y de los principios que orienten la ne-gociación de los convenios docencia servicio entre las IPS y la IES. La racionalidad en la definición de costos, beneficios y responsabilidades en la formación de residentes es un compromiso social y ético que debería reflejarse en el valor de las matrículas, sin desconocer que las IPS y las IES tienen responsabilidades con la productividad, eficiencia, calidad y sostenibilidad de sus actividades misionales.
El balance final de la ley en este apartado se medirá según la propor-ción de la remunerapropor-ción del contrato especial que el residente tendrá que destinar al pago de su matrícula.
De otro lado, parte de los problemas de la educación médica en el país se explican porque las normas y los instrumentos del sistema de edu-cación superior no “entienden” los procesos formativos que ocurren en las instituciones asistenciales, las relaciones que se generan entre éstas y las IES, ni las condiciones de los estudiantes, internos y residen-tes que se forman en los servicios hospitalarios.
Lo anterior ha derivado en la expedición de disposiciones complemen-tarias desde el sector salud que plantean grandes desafíos para la arti-culación de políticas, estrategias y acciones intersectoriales.
Hoy, los requisitos para la aprobación de los programas de residencia médica hacen parte de las normas del sistema de educación superior (Ley 1188 de 2008 y Decreto 1295 de 2010) mientras que el desarrollo de la relación docencia servicio (Ley 1164 de 2007 y Decreto 2376 de 2010), los escenarios de práctica, los hospitales universitarios (Leyes 1164 de 2017 y 1438 de 2011) y las becas crédito (Ley 100 de 1993) hacen parte de normas del sistema de salud. Además, los requisitos de acceso a los programas de residencia y el valor de las matrículas son definidos de manera autónoma por cada IES.
Los espacios de coordinación intersectorial que se han creado hasta hoy, como la Comisión Intersectorial de Talento Humano en Salud y el Consejo Nacional de Talento Humano en Salud, han mostrado acciones plausibles, pero no constituyen soluciones de fondo a los problemas estructurales de articulación de los sectores salud y educación. Por lo antes expuesto, se requiere la creación de un sistema nacional de residencias médicas que conjugue todos estos elementos en una unidad normativa y esté bajo la dirección de una entidad que com-prenda las especificidades de la formación médica especializada. Crear este sistema implica hacer ajustes complejos, como modificar la Ley 30 de 1992, y dar a la academia un rol protagónico en su orientación y gestión, mediante su participación en los organismos decisores o bajo la figura de delegación de funciones públicas, que en todo caso seguirían siendo supervisadas por el estado. En parte, estas propuestas están delineadas en las recomendaciones de la Co-misión para la Transformación de la Educación Médica en Colombia que se puede consultar en:https://www.minsalud.gov.co/sites/rid/ Lists/BibliotecaDigital/RIDE/VS/MET/recomendaciones-comision-para-la-transformacion.pdf.
La Ley 1917 de 2018 estableció que su objeto era la creación del Siste-ma Nacional de Residencias Médicas, pero su articulado no tiene ese alcance. No se observan disposiciones orientadas a superar la frag-mentación normativa e institucional actual ni propuestas para conci-liar la formulación de políticas públicas con la autonomía universitaria. Este hecho explica en gran medida la incertidumbre sobre la aplicación de la ley y sus efectos, en instituciones que están sometidas a mar-cos normativos distintos en materia laboral, contractual, presupuestal y administrativa.
Capítulo aparte merece lo relacionado con la suficiencia y distribu-ción regional de los médicos especialistas. En principio, la Ley 1917 de 2018 no fue concebida con este propósito; sin embargo, al plantearse un objetivo tan ambicioso, como la creación del sistema nacional de residencias médicas, cabe revisar en qué medida contribuye con ese objetivo. La distribución regional de los médicos especialistas, y del talento humano de cualquier área del conocimiento, obedece a temas estructurales de carácter social, económico y cultural que exceden el presente análisis.
Se estima que el país cuenta con cerca de 27.500 médicos especialis-tas, concentrados en los grandes centros urbanos de la zona central del país, mientras que importantes grupos de población de algunas regiones, áreas rurales y alejadas no tienen acceso adecuado a la aten-ción especializada.
importancia regional como Cúcuta, Pasto y Villavicencio no cuentan con programas de residencias médicas, a pesar de tener la infraestruc-tura hospitalaria y las condiciones básicas para ello.
La ley define que el gobierno podrá establecer incentivos diferenciales para los residentes que cursen programas de especialización priori-tarios para el país (art. 5, par 2) y deberá hacer un diagnóstico sobre necesidades de médicos especializados como insumo para una política que fomente su formación (art. 15). Pero no hay disposiciones que faciliten, por ejemplo, la articulación del acceso a los programas de residencia, con el ejercicio médico en regiones desatendidas antes, du-rante o con posterioridad a la realización de la especialización. De otro lado, cada año se ofrecen cerca de 1.800 cupos para ingresar a estos programas, cifra insuficiente para las expectativas de los más de 5.500 nuevos médicos que anualmente se gradúan en el país. Aunque algunos tienen la posibilidad de salir del país para continuar su for-mación, la mayoría se quedan como médicos generales en un sistema de salud que no les permite un ejercicio resolutivo que conlleve a un mejor reconocimiento social y económico.
Es cierto que el aumento de la oferta de programas y cupos de resi-dencia médica depende de la iniciativa de las IES y de la disponibilidad de escenarios de práctica. Sin embargo, se requieren señales claras del gobierno frente a las necesidades y prioridades en la formación médi-ca especializada, por regiones y áreas de especialización, la concreción de incentivos económicos y no económicos, vinculados a la calidad, para IES, IPS y residentes, así como la racionalización de los trámites para la apertura de programas y cupos.
En este contexto, es de gran importancia fortalecer la medicina fa-miliar como una estrategia que permitirá, no solo avanzar en el desa-rrollo del modelo de atención integral territorial, sino convertirse en una alternativa atractiva para que una parte importante de médicos continúen su formación de posgrado.
En síntesis, la expedición de la Ley 1917 de 2018 constituye un gran avance en la protección y mejoramiento de las condiciones de los mé-dicos residentes, cuyo alcance dependerá de la forma como el gobier-no oriente su implementación y las IPS e IES asuman sus responsabi-lidades, pero deja aún pendiente la tarea histórica de consolidar un sistema nacional de residencias médicas.
Este sistema, deberá diseñarse para ser dirigido por un organismo que entienda las particularidades de la educación médica especializada y conduzca con acierto los procesos educativos y asistenciales, privile-giando la acción autónoma de las instituciones comprometidas con la calidad. Deberá incluir estrategias para el acceso equitativo a las residencias médicas, con soluciones concretas a las necesidades y condiciones de las regiones desatendidas del país.
Finalmente, el sistema deberá fortalecer la confianza de la sociedad en los residentes y especialistas, y de estos hacia las instituciones de salud y educación donde se forman y ejercen su profesión.
Á r tículo original
Recibido: 12 | 09 | 2019
Aprobado: 23 | 10 | 2019
Risk Factors in Chronic Diseases – Control with an Active
Epidemiological Surveillance System: one step further
with the STEPwise model
Factores de riesgo en enfermedades crónicas. Control con
un sistema activo de vigilancia epidemiológica: un paso
más allá con el modelo STEPwise
Fatores de risco em doenças Crônicas. Controle com um Sistema de
Vigilância Epidemiológica Ativa: Um passo adiante com o modelo STEPwise
Summary
It has long been known that chronic diseases are often the result of pro-longed exposure to certain environmental, lifestyle or socio-economic fac-tors. It is also recognized that chronic diseases can be prevented, detected and controlled; but the reality is that the disease profile in a developing country like Colombia demonstrates a large burden of chronic diseases, reflected in most of its communities. This problem is also the result of an erroneous public health approach, focusing on medical treatment for the later stages of the disease, living prevention to a secondary role.
At the individual level, a health system like Colombian’s framework do not perform enough work and efforts for early detection and rapid actions to address modifiable risk factors. Individual and population-based measures against chronic disease risk factors are carried out sporadically for some people, but not as a preventive public policy.
Therefore, complimenting the need for activities on the determinants of popu-lation health, the purpose of this proposal is directed to the management and control of these deficiencies through the implementation of an active survei-llance system. Using the World Health Organization step-by-step model as the conceptual framework, this specific surveillance system is established as a new strategy through which health data at the community level can be analyzed, expanded, and integrated into existing general public health surveillance and the infrastructure of the Colombian’s health programs. As a result, this document intends to lay out the foundations for these new strategic tools to inform suitable planning with the adaptation of interventions; aiming at achieving optimal early detection and rapid intervention of risk factors. Closing these gaps should be another step towards reaching a preventive approach to address the enormous burden of chronic diseases for the Colombian population.
Keywords: chronic diseases, non-communicable diseases, epidemiological surveillance, risk factors, public health, active surveillance, WHO STEPwise model.
Gabriel Tadeo Rodríguez iD orcid.org/0000-0001-5975-426X School of Public Health and Health System University of Waterloo
Master of Public Health Ontario, Canada
Correspondencia: [email protected] DOI: https://doi.org/10.18270/rsb.v9i2.2791
How to cite:
Rodríguez GT. Risk Factors in Chronic Diseases. Control with an Active Epidemiological Surveillance System: One step further with the
Resumen
Desde buen tiempo atrás, se es conocido que las enfermedades crónicas suelen ser consecuencia de una exposición prolonga-da a ciertos factores ambientales, de estilo de viprolonga-da o socioeco-nómicos. Igualmente se reconoce que las enfermedades cró-nicas pueden prevenirse, detectarse y controlarse, la realidad es que el perfil de la enfermedad en Colombia demuestra una gran carga de enfermedades crónicas reflejadas en la mayoría de sus comunidades. Este problema es también el resultado de un enfoque de salud pública erróneo, centrado en el tratamien-to médico para las últimas etapas de la enfermedad, dejando la prevención a un papel secundario.
A nivel individual, los marcos del sistema de salud colombiano no realizan el trabajo y los esfuerzos suficientes para la detec-ción temprana y las acciones rápidas para abordar los factores de riesgo modificables. Los medidas individuales y poblaciona-les contra factores de riesgo de enfermedades crónicas, en rea-lidad, se llevan a cabo esporádicamente para algunas personas, pero no como una política pública preventiva.
Por lo tanto, complementando la necesidad de actividades sobre los determinantes de la salud poblacional, el propósito de esta propuesta está dirigido al manejo y control de estas deficiencias mediante la implementación de un sistema de vigilancia activa. Teniendo el modelo paso a paso de la Organización Mundial de la Salud como marco conceptual, este sistema de vigilancia espe-cífico se establece como una nueva estrategia mediante la cual los datos de salud a nivel comunitario pueden analizarse, ampliarse e integrarse en la vigilancia de salud pública general existente y la infraestructura del programa de salud colombiano. Como resul-tado, este documento tiene la intención de establecer los funda-mentos de estas nuevas herramientas estratégicas para informar la planificación territorial con la adaptación de las intervenciones, con el objetivo de lograr una detección temprana óptima y una rápida intervención de los factores de riesgo. Cerrar estas brechas debe ser otro paso hacia el logro de un enfoque preventivo como abordaje de la enorme carga de enfermedades crónicas para la población colombiana.
Resumo
Há muito tempo sabe-se que as doenças crônicas são geral-mente o resultado de uma exposição prolongada a certos fato-res ambientais, de estilo de vida ou socioeconômicos. Também se reconhece que as doenças crônicas podem ser prevenidas, detectadas e controladas, porém o perfil de doenças na Co-lômbia monstra uma grande carga de doenças crônicas refle-tida na maioria das comunidades. Esse fato reflete uma abor-dagem errada da saúde pública, focada no tratamento médico para as fases posteriores da doença, ficando a prevenção em um papel secundário.
No nível individual, as estruturas do sistema de saúde colom-biano não fazem esforço suficiente para detectar precocemen-te as doenças e agir rápidamenprecocemen-te para lidar com os fatores de risco modificáveis. Medidas individuais e populacionais contra fatores de risco para doenças crônicas são esporádica e par-cialmente realizadas, mas não maciçamente como política pú-blica preventiva.
Portanto, complementando a necessidade de atividades so-bre os determinantes da saúde da população, o objetivo des-ta proposdes-ta é direcionar ao gerenciamento e controle dessas deficiências por meio da implementação de um sistema de vigilância ativo. O modelo de Passo a passo, proposto pela Organização Mundial da Saúde foi aplicado, trata-se de um sistema de vigilância específico, estabelecido como uma nova estratégia pela qual os dados de saúde no nível da comunida-de pocomunida-dem ser analisados, ampliados e integrados à vigilância da saúde pública geral e infraestrutura existentes do programa de saúde colombiano. Este documento pretende estabelecer novas ferramentas estratégicas para informar o planejamen-to terriplanejamen-torial adaptando intervenções para conseguir detectar precocemente o fator de risco e interví-lo rápidamente. Pre-encher essas lacunas contribui para uma abordagem preven-tiva para enfrentar o enorme fardo de doenças crônicas da população colombiana.
Palabras claves: enfermedades crónicas, enfermedades no transmisibles, vigilancia epidemiológica, factores de riesgo, salud pública, vigilancia activa, stepwise.
Palavras-chave: doenças crônicas, doenças não
transmissíveis, vigilância epidemiológica, fatores de risco, saúde pública, vigilância ativa, stepwise.
Introduction and Justification
The current burden caused by chronic
diseases
Chronic diseases(CD) or non-communicable diseases (NCD), or pathologies other than those caused by in-fectious agents, include a long list of conditions such as diseases of the cardiovascular system, diabetes, chro-nic obstructive pulmonary disease (COPD), the mayor
agencies such as the World Health Organization (WHO) have been warning about the gradual increase in CD, considering the problem as a current epidemic in both developed and developing countries (4,5).
In a country like Colombia, data from 2012 shows that 67% of all deaths, and 80% of all disease burden are due to CD, especially cardiovascular diseases, can-cer, diabetes mellitus and COPD. This phenomenon is much higher than infectious diseases, responsible for 11% of all deaths, followed by violence-homicide in 17% and traffic accidents in 5.4% (6). Compared to countries in the region, in Colombia, the mortality rate from heart disease highly exceeds countries such as Peru, Chile, El Salvador and Ecuador (7). Consequently, countries with high prevalence of NCD as Colombia bear the economic consequences in term of loss of
productivity and constant drain of services (see also figures 1, 2, & 3)
However, although chronic diseases such as diabetes and cardiovascular disease pose serious health risks, several studies have shown that these diseases can be controlled and prevented through modification of risk factors (8, 9). A diabetes prevention program establis-hed that modification of eating and exercise habits de-creases the probability that individuals with impaired glucose tolerance will develop type 2 diabetes (10). Similarly, clear correlated evidence has been observed since one of the first cardiovascular-related research, the Framingham Heart Study. This study indicates that overweight, smoking, lack of exercise, and unhealthy eating habits are all related to the development of heart disease (11), and that the modification of these risk fac-tors can reduce mortality rates from heart disease (12).
Fig. 1: Main Causes of Mortality in Latin America & the Caribbean 2008
Source: Osorio MA et al. (2012). “Así Vamos en Salud”. Annual Report, Chapter 4. Data retrieved from Regional Observatory for Health – PAHO 2012.
Fig. 2: Main Causes of Mortality in Colombia 2010
Source: Osorio MA et al. (2012). “Así Vamos en Salud”. Annual Re-port, Chapter 4. Data extracted from Vital Statistics– DANE 2010.
0 2 4 6 8 10 12 3,7 4,14 6,29 7,65 9,57 Vi ol en ce a nd hom ic ide In flu en za a nd p ne um on ia D ia be te s m el lit us Ca rd io va scu la r d is ea se H ea rt is che m ic d is ea se 0,0 10,0 20,0 30,0 40,0 50,0 60,0 70,0 64,6 40,5 30,0 24,7
15,1 14,8 14,7 14,0 13,3 11,4
Is che m ic he ar t d is ea se Vi ol en ce a nd hom ic ide Ca rd io va scu la r d is ea se Ch ro ni c o bs tru ct iv e p ul m on ar y D ia be te s m el lit us Re sp ir at or y i nf ec ti on s O th er g as tr oi nt es ti nal d is ea se s H yp er te nsi ve d is eas e Ro ad a nd t ra ffi c a cc id en ts Ur ina ry t rac t i nf ec ti on s D ea th r at
e X 1
Current limitations of epidemiological
surveillance systems for chronic diseases
In general, epidemiological surveillance systems are classified into two types: active or passive (13). Active
surveillance is initiated by an agency, such as a
De-partment or Ministry of Health, in which the agency regularly or periodically requests or seeks information or data from its various agencies or provider entities. Conversely, passive surveillance is initiated by the data source, often a medical center, clinical facility, labora-tory, hospital, etc., rather than the agency (department or Ministry of health); in which, this provider routinely supplies data to the agency (14). In the health sector, most epidemiological surveillance systems worldwide are passive, because they are financially cheaper and easier to run (15).
The WHO defines epidemiological surveillance as “the permanent and systemic collection, location and analysis of data and information, added to the perti-nent dissemination thereof, for those groups of indi-viduals who need to be informed, so that based on this, timely actions can be taken”. The Atlanta Cen-ter of Disease Prevention and Control (CDC) goes a step further and establishes the use of surveillance to
Fig. 3: Chronic Disease Behavior and Main Causes of Mortality in Colombia
Source: Adaped from Osorio MA et al. “Así Vamos en Salud”, Annual Report -2012, Chapter 4 & Pulido A. “Así Vamos en Salud”, Annual Report -2009. Data extracted from Vital Statistics– DANE 2010.
develop, implement and evaluate public health poli-cies and actions (16). However, as we shall see below, these concepts of surveillance apply and function per-fectly for infectious diseases, but to a much lesser stand for chronic or non-communicable diseases (NCD). In general, epidemiological surveillance systems for chro-nic diseases show the following flaws:
First, there is an inappropriate dissemination of findings and reporting from ongoing NCD surveillance systems. With marked discrepancy with infectious disease, cu-rrently, the goal of ongoing or long-term surveillance practices for NCD is monitor trends over time, and of-ten do not provide an immediate public health respon-se. By contrast, lethal infectious diseases are conside-red a national, regional or local threat, and therefore, a notifiable and mandatory reportable disease. Thus, cases of reportable infectious diseases are identified by a physician or practitioner or other health care provi-der according to standard case definitions. The case is then reported to the health local and provincial health authorities, prompting, usually, a public health action or response (17). In other words, unfortunately the long-standing outbreaks and coming epidemics from non-communicable diseases are observed and evalua-ted with different lenses, within a passive perspective
0,0 10,0 20,0 30,0 40,0 50,0 60,0 70,0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
51.6 55.1 55.6 56.7 55.5 56.2
58.4
61.4 61.7 61.7 64,7
61.4
64.6
32.4 33.7 34.7 33.3 33.0 33.3 32.2 32.3 32.9 32.1 32.5 30.9 30.0
14.8 17.1 16.6 17.2 17.3 18.1 17.6 16.9 16.6 16.2 16.5 14.0 15.1
10.1 10.4 10.9 10.6 10.4 10.5 10.3 10.6 10.5 10.8 10.2
Second, the reportable disease concept is biased and data for NCD is incomplete and often they are not ti-mely. The reportable disease concept implies for di-seases in which timely information regarding indivi-dual cases is necessary for prevention and control. But clearly, timeliness is a priority attribute just for outbreak detection, mainly for infectious diseases. Moreover, a disease mandated as reportable includes: “one that it may be associated with severe illness and death, it may require specialized treatment available through public health, it has the potential to cause outbreaks and it can be prevented through interventions” (18). Thus, although CD meets all these criteria, unfortunately the concept is eminently biased for infectious diseases, with a passive response in order for CD, or differing the problem often for too late actions.
Third, the data collection is disease-centered and not patient-centered; that is, there is a multiplicity of cate-gorical system centered on syndromes and diseases.
Countries around the world have a variety of survei-llance systems that are not integrated and not linked, producing an extreme burden on reporting sources, lots of duplication, and lack of appropriate use of the data. Chaotic situation that is happening due to the ways in which different reporting systems have been set up independently; to the point that data volume and management has become complex and overwhel-ming. There is currently a trend, including developed and developing countries, to organize an epidemiolo-gical surveillance system for each disease or syndrome considered a threat to the population; emphasizing the current curative approach, and leaving health promo-tion and disease prevenpromo-tion, with their risk factors, in a secondary role (19). (see also figures 4, 5 & 6)
Fig. 4: Infectious Diseases vs. Chronic Diseases: Levels of Response and Actions in Public Health.
Fig. 5: Epidemiological surveillance systems. Applicability in infec-tious diseases with minimal use in chronic diseases.
Fig. 6: Differences between active and passive epidemiological sur-veillance systems*
Source. CDC Atlanta, 1992
*Adapted from McNabb, S. et al. (2016)
Infectious Diseases
(Reportable Diseases) Agents: Risk FactorsChronic Diseases
Case Identified (Suspected / Confirmed)
Community Studies (surveys)* Evolutionary monitoring
patterns
Immediate Public
Actions without immediate Passive response public actions.
Examples of Surveillance Systems* WHO – STEPwise Instruments for chronic diseases.
*ORRFSS – Ontario Rapid Risk Factor Surveillance System
Surveillance is… Information for action
Surveillance
Collection Analysis Interpreting Dissemination
Actions in Public Health
• Prioritization of sites
• Disease planning, implementation and evaluation
• Research
• Control • Prevention
Passive & Active Surveillance
Pasive Active
• Initiated by service providers such as hospitals, labo-ratories, health care cen-ters… etc.
• Relatively simple without re-quiring extensive resources. • Information tends to
be incomplete.
• Initiated by a public health agency. • Tends to require many
more resources. • Information is much
In this way, the immense burden represented by chronic diseases can be observed, added to the li-miting developments of their surveillance system. It is evident that CD, and in particular their risk factors, require a different management than the current cu-rative approach, based eminently on the disease. The first measure to address the problem must be through a right preventive approach; improving in the first ins-tance the limitations of surveillance systems on risk factors, with the aim of achieving a timely detection and immediate intervention on them. Thus, the pur-pose of this Discussion Paper will have the following central objectives:
y Highlight the overwhelming burden of chronic di-sease at the global, regional and local levels,
y Document the current limitations of epidemiologi-cal surveillance systems for chronic diseases,
y Stablish an essentially preventive approach to the management and control of chronic non-commu-nicable diseases,
y Lay out the foundations for an active epidemiologi-cal surveillance system as a pressing and essential proposal in public health, oriented to the manage-ment and control of the risk factors for chronic di-seases,
y Describe the World Health Organization’s stepwi-se model as a theoretical framework for the as-sessment of chronic disease risk factors,
y Propose the transformation of the stepwise model as a passive reporting system into an active survei-llance system, shifting the management and control of chronic disease risk factors,
y Propose an additional step to the stepwise model, adding an active surveillance system, based on risk levels, and using referral and counter-referral as a crucial strategy for the management of risk factors,
y Describe the operation of this new surveillance model for chronic diseases with their respective follow-up in a developing country like Colombia, along with response of public actions by the diffe-rent actors responsible for the health and social se-curity system,
y Stablish a proposal for evaluating and monitoring the new epidemiological surveillance model,
y Describe the benefits and potential limitation of this new active epidemiological surveillance system
Methodology
As the relationship between modifiable risk factors and the onset and progression of these diseases has beco-me increasingly clear, the model of the World Health Organization, commonly known as STEPwise (20), has been seen as a promising theoretical framework for early detection of modifiable risk factors, and there-fore, behavioral change interventions. By conducting a survey (basic questionnaire) along with physical and biochemical measurements, the tool and its instru-ments focusses on obtaining core data on individual stablished risk factors that determine the major disease burden, as such: (see also figure 7)
y smoking (daily and occasional)
y insufficient physical activity
y unhealthy/poor diet (daily consumption of less than 5 servings of fruit and vegetables)
y raised blood pressure
y overweight and obesity
y raised cholesterol
y raised blood sugar
The framework had been used exclusively as a mea-surement tool for reporting patterns and trends over time at the community level with national or regional prevalence STEPS surveys, but not as an instrument for individualized behavioral change intervention, or indi-vidual referral for immediate public actions. Thus, ba-sed on this framework, this proposal aims to fulfil this gap by creating an active surveillances system, and tac-kling with a preventive approach chronic disease risk factors at the individual and community level. In other word, complementing the current experience with the stepwise model, this initiative brings or goes one step beyond the current concept and use.
Description of the conceptual
framework
Currently the model is used for collective (community) study of risk factors through steps. That is, by means of a survey (basic questionnaire) together with taking phy-sical, anthropometric and biochemical measurements, the instruments of the model focus on obtaining central data on established risk factors in peoples, which are the determinants of the disease burden for CD. In other
CD surveillance, the model has been used exclusively as a tool to determine chronic disease patterns and trends at the community/population level over time, by
using surveys and subsequent prevalence assessment,
Figure 7. STEPwise model - Evaluative STEPS of risk factors in Chronic Diseases
at local, regional and even national levels (21). Several countries around the world have beneficiated from the stepwise model, highlighting two studies carried out in Colombia:
Measures Step 1
(Self-Report) (Physical) Step 2 (Biochemical)Step 3
Core Socio-economic and demographic
variables, years of education, tobac-co and altobac-cohol use, physical inacti-vity, intake of fruit and vegetables.
Measure weight and height, waist
circumference, blood pressure Fasting blood sugar, total choles-terol
Expanded Core Ethnicity, income, education,
hou-sehold indicators, dietary patterns. Hip circumference, pulse rate HDL-cholesterol, triglycerides Optional (Examples) Other health-related behaviors,
mental health, disability, injury Time walked, pedometer, skinfold thickness Oral glucose tolerance test, urine examination
Source: World Health Organization (WHO - 2015). The STEPwise method of surveillance, available at: http://www.who.int/chp/steps/es/
y The first one is a local study, in 2011, in the city of Medellin, corroborating the critical load of the CD. Whit a basket of 3,138 participants, and a response rate of practically 100%, the study reported tobac-co tobac-consumption of 18.3%, altobac-coholism of 64.5%, inappropriate diet in 81.6%, low level of physical activity in 80%, overweight and obesity in 46.7%, hypertension in 20.2%, diabetes in 7.6% and hy-percholesterolemia in 57.7% of the participating population (22).
y The second is a 2010 regional study, in the pro-vincial of Santander. Report which also corrobo-rated the high prevalence of risk factors of CD in other national morbidities studies, showing that 75% of the population has at least one or two risk factors. As such, using a sample of the provincial adult population, the study revealed high tendency to physical inactivity (70.6%), diabetes (5.7%), hy-percholesterolemia (37.5%), hypertension (19.5%), overweight or obesity (50.7%), tobacco use (8.2%), inappropriate alcohol consumption (25%) and inap-propriate diet (94.9%) (23)
In this way, contrary to the current passive use, the
pre-sent proposal intends to turn the stepwise model into an active epidemiological surveillance system with a preventive approach; adapting it, in the first instance,
as an instrument for individual use (reinforcing in the
short term, the collective or community process), for early detection an immediate intervention for risk fac-tors. That is, by adjusting the model and making use of a referral and counter-referral program, upon a time that risk factors in a patient have been evaluated and detected, immediate public health actions and respon-ses will be carried out on them.
Primary Case Definition
The term ‘primary case definitions’ refers to the crite-ria in which participants in a surveillance system are organized in order to detect and select affected sub-jects or individuals whom are evaluated. By establis-hing criteria, a primary case definition becomes the main insight for clinical alertness, and therefore case findings, among stakeholder and potential sites where the surveillance system will be implemented (sentinel sites) (26).
measures are taken from each participant to detect related risk factors (e.g. weight, blood pressure). And similarly, during the step 3, basic laboratory criteria (biochemical measures, e.g. glycaemia, cholesterol) is established for the confirmation of risk factors (27). Consequently, by using the stepwise parameters to be included on a primary case definition and adapting and turning this approach into a new active surveillan-ce system, the method provides a practical way to clas-sify each participant evaluated. As can be seen ahead, with the use of this method, the participants can be categorized into four main groups or primary cases, according to the level of risk given by the individual accumulation of these factors.
Results
As a discussion document and additional proposal for intervention in public health, which after the descrip-tion of the theoretical conceptual framework, and ba-sed on the primary case definition, the organization and delivery of the new active surveillance for CD, will be as follows:
Implementation and Evaluation Process
Like a population-based surveillance system, all in-dividuals between the ages of 16 and 70 are eligi-ble to participate. However, the implementation in a social health system should be a gradual process. By using Colombia as a case study, the implemen-tation process ought to go first through primary or pilot projects in different locations, in both contri-butory and subsidized schemes. Obviously, local and regional expansion requires the commitment of the regimen administrators (ARS y EPS) to their net-work of services and the other actors of the health security system, including the Ministry of Health, National Institute of Health, local and provincial health units and departments, among others. The establishment of pilot projects in different territorial entities is facilitated by the current infrastructure of the Colombian’ service networks. Location sites or sentinel sites would correspond to the first-level ser-vice delivery networks, including community health centers, primary healthcare centers, and first-level hospitals or policlinics. In the same way, the deve-lopment of the project would be in charge of the personnel currently working on these institutions and service networks; that is, health promoters, nurse assistants, chief nurses, nurse practitioners,
community-based health workers, family doctors, nutritionists, psychologists, etc.; adding to it all the logistics and administrative support for the project development (see descriptive graph of implemen-ting the model at the Colombian’s Health and Social Security System, figure 8)
Thus, before the start of any individual or group in-tervention, the data accumulated by the evaluative process (questionnaire or survey), along with anthro-pometric and biochemical measurements, will be used to categorize individual levels of risk, define case management and referral needs, according to the previously stipulated case definition. Then, at
the zero-risk level (with none or minimal risk factors)
the user (patient) will be motivated to continue with favorable lifestyles, being educated on aspects of doubt or significant potential risk. At level I risk (eva-luated by the questionnaire or one of the physical or biochemical measurements), the individual is clas-sified as low or moderate risk, for whom preventive and supportive measures are provided for the elimi-nation or radical control of these factors. With level
II risk (three risk factors evaluated by the mentioned
measurements), the individual is classified in a high risk, for whom preventive and assisted measures are provided for the elimination and radical control. Fi-nally, at level III risk (with four or more factors) the individual is classified in a high and complex risk, for whom preventive and intensive measures are provided, seeking maximum control and potential elimination of those factors (see also descriptive gra-ph of operability, figure 9).
Analysis Plan & Logistics for
Implementation
To be successful, this new active surveillance system needs to be integrated into a chronic care model for preventing and managing chronic disease, such as the Colombian’ SGSS. Integration that must align with the structure, goals, and values of the regio-nal and provincial health care system and the extent to which it supports efforts to improve chronic ca-re. Therefore, the surveillance system for early de-tection of risk factors becomes a crucial, strategic and supportive tool to enhance and complement all components and management for a chronic disease care model development. Mentioning in detail the logistics, budget and other requirements for this pro-ject development lies beyond the scope of this initial proposal; but it needs to go into detail in a second phase, when decision-makers adopt this initiative to be incorporated in a chronic disease model. Howe-ver, in summary, the main aspects for the develop-ment of this project will be:
Logistics refers to the needs required for the project
implementation, such as personnel, equipment, and the computer software necessary to process the da-ta, including data collection, data entry, plus editing and analyzing of the data. It is highly recommended that updated technology for public health will be used; for example, the use of geographic information sys-tem, such as the ArcGIS software, which in addition of geospatial analysis, it allows the mapping and location of primary cases (29).
Analysis and dissemination of this new surveillance data refers to the process of analyzing the data
appro-priately and disseminating them in a timely manner to those who need to know (see also figure 8). Because some of those who need to know include lay persons, policy makers and administrators, (people with little epidemiologic knowledge or background) the reports need to be simple and easy to understand. The da-ta must be distributed in a regular and timely man-ner to all concerned parties so that control and pre-vention measures can be implemented immediately,
emphasizing the preventive benefits involved in this new surveillance system.
Budget and timeline imply the financial resources and
timeliness that is based on the specifics of the action plan for each year and the general implementation process. It includes cost for personnel, equipment, supplies, and participants, having into consideration additional cost associated with it, and justifying each budget line.
Locations of the project or sentinel sites refers to the
places where data are gathered from a limited number of sites, aiming to capture and convey individual infor-mation for all the cases in the target population. Spe-cifically, for this proposal, it is having in mind a limi-ted number of supportive stakeholders, such as local community health centers, health units, and medical offices interested in these pilot project.
Community resources refer to other linkages such as
exercise programs, seniors’ centers, patient education classes in community health centers, or home care agencies providing case managers.
Self-management support involves helping patients
and their families acquire the skills to manage their ill-nesses, providing self-management tools such as blood pressure cuffs, glucometers, diets, and referrals to com-munity resources.
Evaluation of this new surveillance systems involves
Fig 8: Information Flow in an Active Epidemiological Surveillance System for Risk Factors in Chronic Diseases (CD) - Follow-Up and Response of Public Actions by the Colombian’ Social and Health Security System
FIg 9: Level of risk according to case definitions & case management framework People with NCD
Risk Factors
• Specific individual health prevention & promotion programs.
• Family Medicine and Nurse Practitioners
• Focus groups/Community preventive-promotional programs
Provincial Health Departments (Secretarias Departamentales de Salud) Source of Reports
• Sentinel Sites • CHC • PHC
• Local Hospitals • Policlinics • Local Networks of CHW
Ministry of Health (Ministerio de Salud)
National Institute of Health (Instituto Nacional de salud)
Local Health Departments (Secretarias Locales
de Salud)
Active Case Patient Referral
(Immediate actions taken)
Data Dissemination
• Provincial Bulletins • INS Surveillance reports • Public Info Dataset
CHC: Community Health Centers (in subsidiary scheme = puestos y centros de salud)
PHCC: Primary health care centres (in contributive scheme = centros de atencion primaria) CHW: Community health workers and health promotes. RFNCD: Risk factors for non-communicable diseases. INS: National Institute of Health (Instituto Nacional de salud)
Level of Risk Case Management Referral Priority
Risk Level I One or two risk factors, either
from self-reported, physical or biochemical measurement
Risk Level 0 None of the risk factors
High complex member: Pre-ventive & Intensive care
High risk member: Preventive & Assisted care
Low & moderate risk member: Preventive & Supportive care
• Individual P & PP* by a FD* or NP*
• Focused groups
• Individual P & PP* by a NP*
• Community P & PP
• Individual P & PP* by a NP*
• Community P & PP
*P & PP = Preventive & Promotional Program *FD = Family Doctor
*NP = Nurse Practitioner
Data Dissemination
Feedback (Provincial policies/strategic
control measures) Feedback (Local policies/strategic
con-trol measures/data analysis) Feedback (Ongoing programs/data
analysis/local measures)
Risk Level II Three risk factors, either from
self-reported, physical or biochemical measurement
Risk Level III Multiple (four or more
Discussion & Conclusions
Colombia, as a developing country, is currently un-dergoing typical demographic and epidemiological transitional periods, which is the direct result of social and economic changes from the Colombian popula-tion (30). For example, since 2009, nearly 6% of the Colombian population was over 65, a proportion that could reach 20% in 2040 if the current trend conti-nues (31). Similarly, over the last two decades, Co-lombia has shown sustainable economic growth and increased urbanization with the corresponding popu-lation exposure to multiple risk factors. Changes that have led to dramatic modifications in lifestyles, levels of physical activity and behavior in general, resulting secondarily in the double burden of disease (infectious and chronic diseases) (32). However, similar to what is currently observed in developed countries, chronic diseases represent the predominant burden; a much
Fig 10. Pilot program design - Active Epidemiological Surveillance System for Chronic Diseases’ Risk Factors during the first eight years.
Adapted from Fortmann Sp et al., Community intervention trials: reflection on the Stanford Five-City Project experience. American Journal of Epidemiology, Vol 142, N. 6, p. 579 (1995), The Johns Hopkins University of Hygiene and Public Health. Evaluative survey A1 to A4 (in yellow). Evaluative Survey B1 to B3 (in orange).
more overwhelming aspect for a country such as Co-lombia, where, in addition to the double burden, the huge phenomenon of violence is added (33).
In addition to the disease burden, the current limita-tions of surveillance systems must be taken into ac-count; in which risk factors for CD (obesity, smoking, inappropriate diet) do not represent an “imminent” threat at the individual or collective level, thereby provoking a passive response. Basic models that in-tervene over the problem with public responses of-ten are too late, or when the disease is in advanced stages. In this way, it is evident that a new approach must be on the agenda, aimed at the control and ma-nagement of CD. Thus, based on the WHO stepwise approach, a new surveillance structure is proposed in this discussion paper, after which the active com-ponent, by modifying the risk factors for CD, is the predominant aspect. By classifying new levels of risk, in addition to the referral process according to the
Project year 0 1 2 3 4 5 6 7
Epidemiologic Surveillance (prime survey)
June
Individual / Community Interventions
Jan
Evaluative-A Survey
Indepen-dent Sample
Eval. A1
June-Dec June-DecEval. A2 June-DecEval. A3 June-DecEval. A4
Evaluative-B survey Longitu-dinal Cohort
Eval. B1
individual needs, this proposal initiative is considered
one step further to the STEPwise method;
comple-menting, therefore the model.
Through their current health and social security sys-tem, a nation like Colombia has an entire infrastructu-re favorable to the implementation and dissemination of the new model, expecting a positive impact in the very short term. Under this path, as an enriching sup-port for the discussion, and closing for this working document, some benefits and useful considerations with the establishment of this new active surveillance system are going to be stated, and some possible limi-tations will also be mentioned.
Making progress in the preventive and
wellness model
The pillars of the preventive and wellness approach is originated in the Ottawa report from1986, in a health promotion document known as The Ottawa Chapter of
Health Promotion (34). This report establishes the need
to transform the current disease-based curative model to a preventive model based on well-being (35). Despite the clarity of the model, almost 33 years later, most nations continue to base their health systems on a curative and disease model, resulting in part in the hazy burden of chronic disease (36). The transformation bases are sum-marized in the following graphic:
Thus, it is evident that the conformation of an active surveillance system, tending towards the early detec-tion and timely acdetec-tion on the risk factors in chronic diseases, represents a basic tool of support for the de-velopment of the preventive and wellness approach.
Supporting action to close the social
inequality gap
In an effort to better assess and modify social inequa-lities in health and their consequences on population well-being, the WHO Commission on Social Determi-nants, over its final report of 2008, “closing the gap
in a generation” recommends the inclusion of
addi-tional information in routine data collection. The re-port (p.182) states that, in addition to the assessment of social determinants in health, surveillance of risk factors of chronic diseases (e.g. tobacco and alcohol consumption, physical activity, diet and nutrition, lite-racy and education levels, means of transport, among others), will represent one of the first steps in creating
policies and immediate actions to address and deal with social and health inequalities (36).
Potential limitations of the new
surveillance system
One of the main limitations with this type of active sys-tem is the difficulty in guaranteeing the personal confi-dentiality of the information. Obtaining motivation and consent from the patient or user to assess personal risk conditions and characteristics is crucial for the proper development of the system. However, this must be accompanied by a total guarantee of the information confidentiality, an aspect that is potentially difficult to comply with, or that may cause mistrust for the user. Similar to mandatory reporting in communicable di-seases (37), reports resulting from the analysis of infor-mation over CD should be oriented with the same gua-rantee of confidentiality, protecting names, addresses and individual information of users; aimed only at te-chnical analysis or public response based on individual
Curative and Disease Model Preventive and Wellness Model
• Prevention is not a priority • Prevention at all points of a continuum
• Based on a provider (usually a doctor) • Integrates an interdisciplinary team
• Disease-based • User-based (patient)
• Reactive, intervening in various states of the disease • Proactive, modifying risk factors
or collective information, respecting and ensuring pri-vacy in the first instance. The task of improving confi-dentiality should be achieved in the short and medium term through continuous education processes for the frontline technical staff in charge of data collection and gathering, as well as the professional staff in charge of monitoring and controlling. Likewise, accompan-ying the task, there must be the support of regional and national legislation that enforces compliance with rules (38). Obviously, the new process cannot run like a loose wheel. The operation of this new surveillance process requires its respective incorporation into a lo-cal, regional and national scheme for the provision of public health services, which in the case of Colombia represents the current general health and social securi-ty system (see also integration diagram, figure 8) Another important limitation is originated in the appa-rent cost for the development of the system. Although pilot projects in a country like Colombia are expected to be part of the prevention and promotion programs established in the social security law (39), this implies a new cost of priority re-organizations that might ser-ve as a limiting factor for their implementation. Ob-viously, in the medium-and-long-term the benefits will be much greater than any other cost. It is clear that in any health system, preventive actions over the fi-nal negative impacts on CD, such as productivity loss (healthy life years lost), premature death, and dispro-portionate financial spending on healthcare, so far out-weigh medium-and-long-term huge costs (40).
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Conflicto de intereses
Ninguno declarado por el autor.
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Á r tículo original
Recibido: 06 | 02 | 2019
Aprobado: 26 | 04 | 2019
Comparing the Camry dynamometer to the Jamar
dynamometer for use in healthy Colombian adults
Comparación del dinamómetro Camry con el dinamómetro
Jamar para su uso en adultos colombianos saludables
Comparação dos dinamômetros Camry e Jamar para seu uso
em adultos colombianos saudáveis
Abstract
Objective: Hand grip strength can provide an objective index of general
upper strength, but hand dynamometer has not been validated for use in Colombia. The objective was to determine the interchangeability between Camry electronic and Jamar hydraulic hand grip dynamometers in a popu-lation found on the campus of the Universidad Nacional de Colombia and the elderly living in a community.
Methods: This was a cross-sectional concordance study on 18-88-year-old
males and females. Data regarding their demographics, health, and anthro-pometric variables were collected/measured and the Lin concordance co-rrelation coefficient (CCC) along with Bland-Altman plots were used for evaluating concordance regarding both devices.
Results: One hundred and thirty-three subjects participated in this
stu-dy (average age 47±20.74 years-old). Right hand (RH) grip strength was 32.15±9.96 kg with the Jamar dynamometer and 29.95±9.18 kg with the Camry device. It is worth highlighting that the Jamar instrument presents higher values than the Camry instrument (p <0.05). CCC was only signifi-cant at the population level and for the 40-59-year-old age group. Bland-Altman plots had narrow limits of agreement.
Conclusion: We concluded that the Camry dynamometer could replace
the Jamar dynamometer in the 40-59-year-old age group; furthermore, it would be appropriate for medical use in patient monitoring or follow-up due to the close values observed.
Keywords: hand strength, upper extremity, muscle Strength Dynamometer, cross-sectional study, biostatistics.
DOI: https://doi.org/10.18270/rsb.v9i2.2794
Gustavo Alfonso Díaz Muñoz
iD orcid.org/https://orcid.org/0000-0002-9216-7873 Institute for Research on Nutrition, Genetics, and Me-tabolism, School of Medicine, Universidad El Bosque, Bogotá D.C., Colombia.
Sandra Julieth Calvera Millán
iD orcid.org/https://orcid.org/0000-0002-9823-3958 Nursing School, National University of Colombia, Bogotá D.C., Colombia.
Correspondencia: [email protected] How to cite:
Díaz-Muñoz GA, Calvera-Millán SJ. Comparing the Camry dynamometer to the Jamar dynamo-meter for use in healthy Colombian adults. Rev. salud. bosque. 2019;9(2):18-26.
Resumen
Objetivo. La fuerza de agarre de la mano puede proporcionar
un índice objetivo de la fuerza de los miembros superiores, pe-ro no se dispone de un dinamómetpe-ro de mano validado para su uso en Colombia. El objetivo fue determinar la intercambiabili-dad entre los dinamómetros hidráulicos Jamar y el dinamóme-tro electrónico Camry en una población que se encuentra en el campus de la Universidad Nacional de Colombia y personas mayores que viven en una comunidad.
Métodos. estudio transversal de concordancia realizado en
hombres y mujeres de 18 a 88 años de edad. Se recolectó in-formación sobre variables demográficas, de salud y antropo-métricas. El coeficiente de correlación de concordancia de Lin (CCC) y los gráficos de Bland-Altman se utilizaron para evaluar la concordancia entre ambos dispositivos.
Resultados. Participaron 133 sujetos (edad promedio de 47 ±
20,74 años). La fuerza de agarre de la mano derecha fue de 32,15 ± 9,96 kg con el dinamómetro Jamar y de 29,95 ± 9,18 kg con el dispositivo Camry, destacando que el equipo Jamar presenta valores superiores al Jamar (p<0.05). La CCC solo fue significativa a nivel de la población y para el grupo de edad de 40 a 59 años. Los gráficos Bland-Altman presentaron límites de acuerdo estrechos.
Conclusión. Concluimos que el dinamómetro Camry podría
reemplazar el dinamómetro Jamar en el grupo de edad de 40-59 años; además, sería apropiado para uso médico en el monitoreo o seguimiento de pacientes debido a los valores cer-canos observados.
A wide array of dynamometers is available; they can be discriminated by their measuring mechanism and how the outcome is presented. The Jamar hydraulic dynamo-meter is the currently recognized device for measuring hand grip strength (1,6) and is referred to as the gold stan-dard or reference device for other dynamometer valida-tion by The American Society of Hand Therapists and The American Society for Surgery of the Hand (1,4,6). The Camry electronic dynamometer is a new device, mea-ning that no information is currently available allowing its interchangeability with the Jamar dynamometer.
To the best of the authors’ knowledge, no reports re-garding validation, comparison or correspondence between the hydraulic Jamar and electronic Camry hand grip dynamometers have been published to da-te; this study was thus aimed at evaluating the degree of interchangeability when comparing a Camry to a
Palabras clave: fuerza de la mano, extremidad superior, dinamómetro de fuerza muscular, estudio transversal, bioestadística.
Introduction
A hand dynamometer can be used for measuring up-per extremity strength by hand grip test thereby evalua-ting upper extremity muscular strength and function (1). Hand grip strength is useful as a diagnostic and prog-nostic tool in clinical settings and can be used for deter-mining treatment efficacy (2,3). It can be measured from age four onwards (3,4) since it is a simple method which is recommended for evaluating muscular function in a clinical setting (5) and can be used for determining the strength of muscular, neuronal and skeletal systems (3). Despite its advantages, grip strength is not routinely assessed in clinical practice because the procedure remains unknown (mostly due to difficulty regarding hand grip dynamometer selection) (2), high reference device cost and greater accessibility concerning less costly yet-to-be validated devices.
Resumo
Objetivo. A força de agarramento manual pode fornecer um
índice objetivo da força dos membros superiores, mas um di-namômetro manual validado não está disponível para uso na Colômbia. O objetivo foi comparar os dinamômetros hidráuli-cos Jamar com o dinamômetro eletrônico Camry e establecer a possibilidade de equivalência no seu uso, na população do campus da Universidad Nacional de Colombia e em idosos que moram em uma comunidade.
Métodos. estudo de concordância transversal realizado em
ho-mens e mulheres de 18 a 88 anos de idade. Foram coletadas informações sobre variáveis demográficas, sanitárias e antro-pométricas. O coeficiente de correlação de concordância de Lin (CCC) e os gráficos de Bland-Altman foram utilizados para avaliar a de equivalência entre os dois dispositivos.
Resultados. 133 sujeitos participaram (idade média de 47 ±
20,74 anos). A força de preensão da mão direita foi de 32,15 ± 9,96 kg com o dinamômetro Jamar e 29,95 ± 9,18 kg com o dispositivo Camry, destacando que a equipe do Jamar possui valores maiores que o Jamar (p < 0,05). O CCC foi significativo apenas no nível populacional e na faixa etária de 40 a 59 anos. Os gráficos de Bland-Altman apresentaram limites estreitos de concordância.
Conclusão. Concluímos que o dinamômetro Camry poderia
substituir o dinamômetro Jamar na faixa etária de 40 a 59 anos; Além disso, seria apropriado para uso médico no monitora-mento ou acompanhamonitora-mento de pacientes devido aos valores próximos observados.
