Introduction: Clinical practice guidelines (CPGs) are designed to improve the quality of care and reduce unjustified individual variation in clinical practice. Knowledge of the barriers and facilitators that influence the implementation of the CPG recommendations is the first step in creating strategies to improve health outcomes. The present systematic meta-review sought to explore the barriers and facilitators for the implementation of CPGs. Methods: A search was conducted in the PubMed, Embase, Cochrane, Health System Evidence and International Guideline Library (G-I-N) databases. Systematic reviews of qualitative, quantitative or mixed-methods studies that identified barriers or facilitators for the implementation of CPGs were included. The selection of the title and abstract, the evaluation of the full text, extraction of the data and the quality assessment were carried out by two independent reviewers. To summarise the evidence, we grouped the barriers and facilitators according to the following contexts: political and social, health organisational system, guidelines, health professionals and patients. Results: Overall, 25 systematic reviews were selected. The relevant barriers in the social-political context were the absence of a leader, difficulties with teamwork and a lack of agreement with colleagues. Relevant barriers in the health system were a lack of time, financial problems and a lack of specialised personnel. Barriers of the CPGs included a lack of clarity and a lack of credibility in the evidence. Regarding the health professional, a lack of knowledge about the CPG and confidence in oneself were relevant. Regarding patients, a negative attitude towards implementation, a lack of knowledge about the CPG and sociocultural beliefs played a role. Some of the most frequent facilitators were consistent leadership, commitment of the members of the team, administrative support of the institution, existence of multidisciplinary teams, application of technology to improve the practice and education regarding the guidelines. Conclusions: The barriers and facilitators described in this review are factors that influence the implementation of evidence in clinical practice. Knowledge of these factors should contribute to the development of a theoretical basis for the creation of CPG implementation strategies to improve professional practice and health outcomes for patients.

BackgroundThe family of KIDSCREEN instruments is the only one with trans-cultural adaptation and validation in Colombia. These validations have been performed from the classical test theory approach, which has evidenced satisfactory psychometric properties. The aim of this study was to evaluate psychometric properties of KIDSCREEN-27 children and parent-proxy versions, through Rasch analysis.MethodsThe participants in the present study were two different sets of populations, 321 kids with a mean age of 12.3 (SD 2.6), 41 % 8 to 11 years old and 59 % 12 to 18 years old; and 1150 parent-proxy with an average age of 45.5 (SD 18.9). Psychometric properties were assessed using the partial credits model in the Rasch approach. Unidimensionality, fitting of person and item, response form, and differential item functioning (DIF) were measured.ResultsThe Infit MNSQ in child self-reported version that ranges between 0.71–1.76, and 0.69–1.31 in the parent-proxy version. Scores gathered on Likert forms of 5-response options, person separation was 2.08 for child self-reported version and 2.40 for parent-proxy; reliability was 0.81 and 0.85, respectively. Items reliability was 0.99 on both versions, with separations of 11.92 for child self-reported and 10.83 for parent-proxy. There was not DIF according to the variables sex and age but was present according to socioeconomic status.ConclusionThere was a good fit for items and individuals to the Rasch model. Item separation was adecuate, and person separation improved when the response form was re-codified to four options. The presence of DIF according to socioeconomic status implies a scale’s bias in the measure of HRQoL of Colombian children.

Background: The issue of lower extremity amputation has been in the Colombian political agenda for its relationship with the armed conflict and antipersonnel mines. In 2015 the Colombian Ministry of Health published a national clinical practice guideline (CPG) for amputee patients. However, there is a need to design implementation strategies that target end-users and the context in which the CPG will be used. This study aims to identify users' perceptions about the barriers and facilitators for implementing the guideline for the care of amputee patients in a middle-income country such as Colombia. Methods: Semi-structured interviews were conducted with 38 users, including patients, health workers, and administrative staff of institutions of the health system in Colombia. Individuals were purposively selected to ensure different perspectives, allowing a balance of individual positions. Results: According to participants' perceptions, barriers to implementation are classified as individual barriers (characteristics of the amputee patient and professionals), health system barriers (resource availability, timely care, information systems, service costs, and regulatory changes), and barriers related to clinical practice guidelines (utility, methodological rigour, implementation flexibility, and characteristics of the group developing the guidelines). Conclusions: Our study advances knowledge on the perceived individual and health system barriers and facilitators for the implementation of the CPG for amputee patients in Colombia. Importantly, the governance, financial, and service delivery arrangements of the Colombian health system are determining factors in implementing CPGs. For example, the financial arrangements between the insurance companies and the health care provider institutions were identified as barriers for the implementation of recommendations related to the continuity and opportunity of care of patients with amputations. The design of implementation strategies that successfully address the individual behaviours and the contextual health systems arrangements may significantly impact the health care process for amputee patients in Colombia.

Background: The soft tissues injury in periarticular fractures of the lower extremities determines the proper time to perform bone fixation. Objetive: The aim of this study was to determine the intra and interobserver agreement in the Tscherne classification. Methods: This is a descriptive, prospective study for patients admitted to the Pablo Tobón Uribe Hospital (PTUH) with tibial plateau or tibial pilon fractures. We performed a standardize evaluation using video photography at the time of admission and 24, 48, and 72 h after admission. Fifteen five reviewers who had various levels of training produced a total of 1,200 observations. The intra- and interobserver agreement was assessed using a weighted kappa for multiple raters and more than two categories. Results: Twenty patients were admitted with tibial plateau and tibial pilon fractures. The intraobserver agreement for all 15 raters was kappa 0.81 (95% CI 0.79-0.83), and the interobserver agreement for all 15 raters was kappa 0.65 (95% CI 0.55-0.73). The interobserver agreement at 24 h was kappa 0.67 (95% CI 0.46-0.86). Conclusions:Classifying the severity of soft tissue injury is critical in planning the surgical management of fractures of the lower extremities. Based on our results, we can reasonably argue that the Tscherne classification produced an adequate level of agreement and could be used to standardize and to guide the treatment, and to conduct research studies. Level of Evidence: Level IV, Case Series

Factors that influence the provision of home-based rehabilitation services for people needing rehabilitation: a qualitative evidence synthesis.

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Objetivo: Presentar el estudio mediante el cual se construyó una ruta integral de atención en salud (RIAS) para la atención del paciente amputado de miembro inferior por causas traumática, vascular o diabetes mellitus, cuyo fin es implementar las recomendaciones de la Guía de práctica clínica del paciente amputado y garantizar la atención integral en salud de esta población en Colombia. Con la ruta se pretende orientar a los actores involucrados en la ejecución de intervenciones individuales para el diagnóstico, el tratamiento y la rehabilitación, e impactar en los desenlaces en salud y equidad de esta población. Metodología: Este estudio responde a una estrategia de mejoramiento de la atención en salud. Para esto, se revisó el Manual metodológico para la elaboración e implementación de las rias; se creó el grupo desarrollador de la ruta; se priorizaron y describieron las intervenciones en función del proceso continuo de atención en salud; se evaluó la práctica asistencial actual con grupos focales de pacientes y profesionales; se formularon los resultados esperados en el proceso de gestión y atención en salud (hitos), y se elaboró el diagrama de la ruta. Resultados: A partir de la Guía de práctica clínica se elaboraron 25 intervenciones individuales priorizadas y caracterizadas según el actor responsable, la población objetivo y el entorno. Para cada una de las intervenciones se presentan resultados esperados en salud, calidad de prestación de servicios, aspectos relacionados con la equidad, y la perspectiva de pacientes y actores involucrados con la atención. Se construyeron los indicadores para el seguimiento e implementación de la ruta. Conclusión: Se construyó la primera ruta integral de atención en salud del paciente con amputación de miembro inferior, de acuerdo con los lineamientos del manual del Ministerio de Salud y de la Protección Social.

Lesiones graves y moderadas por accidentes de tránsito en mayores de 60 años. Medellín, Colombia Severe and moderate injuries in people over 60 years of age caused by road traffic accidents in Medellín, Colombia INVESTIGACIÓN ORIGINAL | Resumen | Introducción. Cada día, 3 400 personas mueren en el mundo por un accidente de tránsito (AT); miles sufren lesiones o adquieren una discapacidad cada año por la misma causa. En Colombia, en 2016 se registró una tasa de 92.8 heridos y 14.9 muertes por cada 100 000 habitantes.Objetivo. Describir las características de los AT y el entorno de su atención en mayores de 60 años con lesiones moderadas o graves en Medellín, Colombia, durante el periodo 2015-2016.Materiales y métodos. Estudio descriptivo de las características de personas mayores de 60 años con lesiones moderadas y graves después de un AT.Resultados. Se evaluaron 247 personas, 93.1% con lesiones moderadas; el 94.1% de las lesiones graves ocurrieron cuando se atropelló un peatón. En 60.7% de los AT una moto estuvo involucrada. El puntaje global del WHODAS-II fue de 40.6 y los dominios de funcionamiento más afectados fueron actividades domésticas, actividades fuera de la casa y movilidad; en cuanto a la calidad de vida, se afectó la función física, el desempeño físico y el cambio en salud.Conclusión. Los mayores de 60 años con lesiones por AT fueron, en su mayoría, peatones atropellados por motocicletas. El AT afectó la calidad de vida y el funcionamiento de los pacientes.Palabras clave: Accidentes de tránsito; Anciano; Puntaje de gravedad del traumatismo; Calidad de vida; Evaluación de la discapacidad (DeCS). Seijas-Bermúdez V, Payares-Álvarez K, Cano-Restrepo B, Hernández-Herrera H, Salinas-Durán F, García-García HI, et al. Lesiones graves y moderadas por accidentes de tránsito en mayores de 60 años. Medellín, Colombia. Rev. Fac. Med. 2019;67(2):201-8. Spanish. doi: http://dx.doi.org/10.15446/revfacmed.v67n2.69549. | Abstract | Introduction: Every day, 3 400 people are killed in road traffic accidents (RTA) in the world; thousands are injured or disabled each year from the same cause. In Colombia, a rate of 92.8 injured and 14.9 deaths per 100 000 inhabitants was reported in 2016. Objective: To describe the characteristics of RTA, clinical care and quality of life of people over 60 years of age with moderate or severe injuries in Medellín, Colombia, during the period 2015-2016. Materials and methods: Descriptive study of the characteristics of people over 60 years of age with moderate and severe injuries after a a RTA. Results: 247 people were included in the study, of which 93.1% had moderate injuries; 94.1% of the severe injuries occurred when a pedestrian was hit. In 60.7% of the RTA, a motorcycle was involved. The overall WHODAS-II Score was 40.6 and the most affected operational domains were domestic activities, activities outside the home and mobility. In terms of quality of life, physical function, physical performance and change in health were affected. Conclusion: People over 60 years of age with RTA inju...