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Background and Aims There is a growing need for evidence based answers to multimorbidity, especially in primary care settings. The aim was estimate the prevalence and patterns of multimorbidity in a Mexican population of public health institution users ≥60 years old. Methods Observational and multicenter study was carried out in four family medicine units in Mexico City; included older men and women who attended at least one consultation with their family doctor during 2013. The most common diseases were grouped into 11 domains. The observed and expected rates, as well as the prevalence ratios, were calculated for the pairs of the more common domains. Logistic regression models were developed to estimate the magnitude of the association. Cluster and principal components analyses were performed to identify multimorbidity patterns. Results Half of all of the patients who were ≥60 years old and treated by a family doctor had multimorbidity. The most common disease domains were hypertensive and endocrine diseases. The highest prevalence of multimorbidity concerned the renal domain. The domain pairs with the strongest associations were endocrine + renal and hypertension + cardiac. The cluster and principal components analyses revealed five consistent patterns of multimorbidity. Conclusions The domains grouped into five patterns could establish the framework for developing treatment guides, deepen the knowledge of multimorbidity, develop strategies to prevent it, decrease its burden, and align health services to the care needs that doctors face in daily practice.

Background: In December 2006, Seguro Popular (SP) implemented the Medical Insurance Century XXI program (SMSXXI) to provide public healthcare insurance to children under five years old who lack social security. SMSXXI aims to increase access to health services, reduce out-of-pocket health-related expenditures (OOPHE), and lower health inequities. Methods: We assessed the effects of SMSXXI on health outcomes and financial protection for Mexico's children using multiple nationally representative surveys and administrative data sources spanning the period between 2001 and 2016. The identification of effects relied on detailed hospital level affiliation data mapping the geographical expansion of the program's coverage across the country over time. The final outcomes were neonatal and infant mortality, self-reported morbidity (health status, flu, and diarrhea) and child's height. Intermediate outcomes were OOPHE, hospital discharges and quality of service provision. Effects controlled for fixed and time-variant confounders using double- and triple-difference estimation strategies. Where feasible, we also estimated effects using exogenous variation in program eligibility rules that limited enrollment in SMSXXI to children born after December 1, 2006. Findings: SMSXXI reduced the infant mortality rates of conditions covered by the program by 5.3%. The effects were largest in high baseline mortality areas. Long-run health effects, eight years after the onset of SMSXXI, were reflected in a 0.44 cm average increase in height for birth cohorts exposed to the program, and an average effect on height of almost 1cm for low-income populations. Approximately three to six years after the program started, children reported having better health status and lower incidence of the flu and diarrhea. The program led to a 10% reduction in OOPHE, primarily from hospital-related expenses. No effects were detected on hospital discharges, suggesting that the program may not have increased utilization. Rather, improvements in the quality of healthcare and specialized personnel are likely channels driving improvements in health outcomes. Interpretation: SMSXXI covers uninsured, primarily low-income populations who may be most at risk from the financial and health consequences of costly medical interventions. The program transfers resources from the federal level to states and providers for the enrollment and treatment of children under five years old. Transfers are conditioned on the compliance of medical facilities with accreditation standards (criteria of capacity, quality and safety for the patient). Funds are used to strengthen local health services through the purchase of equipment and staffing of medical specialists. We use previously unexploited sources of exogenous variation in program assignment to identify causal effects on health and financial risk. Results suggest that SMSXXI reduced infant mortality, improved long-run health as proxied by self-reported morbidity and child height, and protected low-income families from the adverse economic consequences of health shocks. Funding: Funding for this study was provided through Inter-American Development Bank (IDB) Technical Cooperation ME-T1307. Declaration of Interest: Dr. Celhay has nothing to disclose. Dr. Martinez has nothing to disclose. Mr. Munoz has nothing to disclose. Mrs. Perez has nothing to disclose. Dr. Perez Cuevas has nothing to disclose. Ethical Approval: The study consists in a secondary data analysis of several databases; all these databases have the de-identified data; thus, it is not possible to trace any of the data to the actual individual. In accordance to the Internal Regulation of the Interamerican Development Bank, this secondary data analysis can be considered exempt of institutional review board approval.

Background: Upper respiratory infections are the principal cause of morbidity in children

ResumenIntroducciónLa evaluación de la calidad de la atención del recién nacido con complicaciones es un elemento indispensable para las estrategias de mejora orientadas a reducir las tasas de mortalidad neonatal. El objetivo de este trabajo fue evaluar la calidad de atención técnica e interpersonal en el manejo de la taquipnea transitoria del recién nacido (TTRN) de pacientes afiliados al Seguro Médico Siglo XXI.MétodosSe realizó un estudio transversal en 61 hospitales de la Secretaría de Salud, que durante el primer semestre de 2011 reportaron al menos dos casos de TTRN. Se analizaron diferentes variables con respecto a la madre, el embarazo, el nacimiento y las complicaciones neonatales, así como intervenciones realizadas al recién nacido y condiciones de salud al egreso. Para medir la calidad de atención, se definieron y validaron indicadores de calidad en los ámbitos de la prevención, diagnóstico y tratamiento.ResultadosSe analizaron 256 expedientes de casos con diagnóstico de TTRN. El 8.9% de las madres tenía alguno de los factores de riesgo (asma, diabetes) y el 53.5% presentó complicaciones en el embarazo. El 60% de los casos de TTRN nacieron por cesárea; un tercio tuvieron bajo peso al nacimiento y el 14% fueron trasladados a otro hospital. En cuanto a los indicadores de calidad, en el rubro de prevención se identificó que en más del 90% se registraron los factores de riesgo (tabaquismo, asma, parto por cesárea); los de diagnóstico reflejaron que en el 86-98% se buscaron manifestaciones de insuficiencia respiratoria. Los de tratamiento lograron cifras satisfactorias para las medidas de monitorización y soporte.ConclusionesLos resultados permiten considerar que la mayoría de los casos con TTRN recibieron un tratamiento apropiado. Es recomendable desarrollar estrategias efectivas, como reducir la creciente tasa de partos por cesárea, para prevenir la TTRN.AbstractBackgroundEvaluation of the quality of care of the newborn with complications is an indispensable element for the improvement of strategies directed to reduce newborn mortality rates. The aim of this work was to evaluate the quality of technical and interpersonal care in the management of transient tachypnea of the newborn (TTN) of patients affiliated with the program “Medical Insurance Siglo XXI”.MethodsA cross-sectional study was conducted in 61 hospitals affiliated with the Health Ministry with at least two cases of TTN during the first semester of 2011. Variables such as mother's health, pregnancy, birth and birth complication characteristics were analyzed. Also, newborn interventions and health conditions upon discharge were included. To measure the quality of care according to prevention, diagnosis and treatment, quality indicators were defined and validated.ResultsWe analyzed 256 case files with a diagnosis of TTN; 8.9% of the mothers presented risk factors (asthma, diabetes) and 53.5% had complications during pregnancy. There were 60% of cases with TTN born by cesarean delivery; one third of these children had low birth weight and 14% were transferred to another hospital. As for the quality indicators in the area of prevention, more than 90% of risk factors (smoking, asthma, cesarean delivery) were identified. Diagnostic indicators showed that 86-98% of respiratory distress symptoms were sought. Indicators of treatment achieved satisfactory figures for monitoring and support measures.ConclusionsPrevention, diagnosis and treatment indicators made it possible to consider that most TTN cases received appropriate treatment. It is advisable to develop effective strategies to prevent TTN, such as increasing efforts to reduce the increasing rates of cesarean deliveries.

Background The ongoing influenza A (H1N1) pandemic stroked Mexico and posed a huge challenge to the medical care and public health systems. This report analyzes the clinical course and process of care of patients who died due to atypical pneumonia and fulfilled the clinical criteria of suspected case of novel influenza A (H1N1) virus infection. Methods We conducted a retrospective analysis of a series of 38 patients who died between April 7 and April 28, 2009 at Instituto Mexicano del Seguro Social (IMSS) hospitals due to severe pneumonia and respiratory distress. These cases coincided with the beginning of the outbreak, so patients did not undergo laboratory testing to diagnose influenza. According to IMSS and CDC criteria, post-hoc analysis allowed considering the presumptive diagnosis of S-OIV infection. A multidisciplinary group analyzed the information from the clinical charts, laboratory tests, radiographic studies and death certificates, using descriptive statistics. Results Most cases were middle-aged (mean 33 years, range: 4–62 years) and previously healthy; 18.4% had an underlying chronic disease, 23.7% were obese and 7.9% were current smokers. None had received the seasonal influenza vaccine; they had cough (92%), fever (86.8%), and malaise (73.7%). The median time from disease onset to hospital admission was 6 days (range 0–8 days). All were admitted to the intensive care unit with pneumonia and/or respiratory distress. Average time from disease onset to death was 8 days (range 4–18 days). Conclusions An increased number of severe cases of atypical pneumonia in previously healthy adults highlight the importance of the availability of a timely surveillance system able to identify sudden increases in the number of cases or presentation of apparently known diseases.

Vitamin A deficiency (VAD) has been closely related to acute respiratory infections (ARI), although information is still incomplete; for example, the frequency of VAD in children5 years of age with pneumonia is not known, and the conditions associated with VAD have not been identified. This study was conducted to gain insight into the status of vitamin A in children with pneumonia. A secondary objective was to identify the sociodemographic, individual, and nutritional factors associated with VAD in these children.A cross-sectional study was conducted in the Mexican state of Hidalgo, one of the poorest in the country. Children with community-acquired pneumonia treated at nine public hospitals were included. Information was obtained by interviewing mothers, and ascertainment of vitamin A status was performed with relative-dose-response (RDR) test.A total of 422 cases were included. VAD was identified in 17.8% of children; 50.3% showed normal results, 24.6% had liver reserve depletion, and 7.3% showed results attributable to the infectious process. Variables associated with VAD were as follows: age2 months (OR 3.44, 95% CI: 1.84-9.24); children6 months of age fed with formula (OR 0.37, 95% CI: 0.15-0.91), and affiliation with the Mexican Social Security Institute (IMSS) health system (OR 0.40, 95% CI: 0.22-0.72).The frequency of VAD in children with community-acquired pneumonia confirms that the problem of deficiency persists in Mexico. The associated factors for VAD found in this study can be taken into account when planning and evaluating vitamin A supplementation activities in populations with high risk for deficiency.

Mass media communication is an important strategy for increasing parental uptake and to promote community participation when large-scale immunization activities are carried out. In Mexico, the National Vaccination Council (CONAVA) launches three immunization campaigns every year accompanied by three vaccination promotion campaigns. This study was conducted to assess whether communication activities to promote CONAVA's Second National Health Week (SNHW) were effective in providing information to mothers about the importance of immunizing their children under five years of age and in prompting them to seek immunization services. A probability sample of mothers living in the metropolitan area of Mexico City and having at least one child under five years old was selected for the study. Four outcome variables were defined as measuring the impact of the campaign: (1) mothers' knowledge about the SNHW; (2) mothers' comprehension indicating how well they understood the campaign messages (aware, partly aware and unaware); (3) mothers' motivation, i.e. whether or not they sought out immunizations for their children under the age of five and (4) mothers' opinion of how well they liked the messages. A total of 935 mothers were interviewed; 88.2% knew about the SNHW, 64.3% were aware that the campaign aimed to provide immunizations, and most held a favorable opinion about the messages. Among aware mothers, 87.5% of their children received immunizations. In this group 72.1% were prompted by the information in the campaign to seek immunizations for their children while 27.9% had to be personally invited to participate in the campaign. The latter occurred either when health workers or volunteers visited mothers in their homes or by soliciting mothers' participation as they visited or passed by immunization health posts. In the unaware mothers group, 72.7% of their children received immunizations; 62.5% of the mothers took their children because of information they received through the campaign while 37.5% had to be personally invited to immunize their children. Mothers with better socioeconomic status were more aware of the campaign, but a high percentage of them did not seek immunizations, while mothers with middle and lower socioeconomic status were motivated to immunize their children through the campaign. Promotion activities and messages communicated through the mass media were appropriate to inform and motivate mothers to seek immunization services for their children.

Background This study was conducted to assess the magnitude of the risk of high morbidity (⩾7 episodes/year) for acute respiratory infections (ARI) in infants attending day care centers (DCC), and to compare the incidence, duration, and severity of ARI in children staying at home (Home). Methods Using a cohort design, 282 infants (DCC, 138 and Home, 144) were followed for a year. Age at entry into the study ranged from 43 days to 4 months. During follow-up, social workers interviewed the mothers weekly to register whether the infants had an ARI. Also, infant health conditions and physical growth were updated monthly. Results ARI incidence was 14 episodes per child/year among DCC infants with a median of 74 sick days, while among children at home, the ARI incidence was 6 episodes, and the median was 40 days. The incidence density ratio for DCC children was 2.33 (95% CI, 2.13–2.54); after adjusting for other covariates, the relative risk increased to 5.27 (95% CI, 3.54–7.83). Conclusions Infants attending DCCs will suffer ARI more frequently than children cared for at home. We did not find seasonal variations in the incidence rates among DCC infants. The quality of care provided at these facilities should be analyzed in more depth for proposing measures to decrease ARI incidence.