Problema de Salud AUGE N°36
Ayudas técnicas para personas mayores de 65 años y más
Juicio del Panel y Evidencia
En personas de 65 años y más con limitación en la movilidad, el Ministerio de Salud SUGIERE USAR cojín antiescaras de celdas de aire por sobre usar cojín viscoelástico.
Comentarios del panel:
► El cojín de celdas de aire podría reducir la incidencia de úlceras por presión en personas con alto riesgo de desarrollarla. Su efecto está determinado por el uso a una presión adecuada dependiente del peso de la persona.
► Los cojines viscoelásticos, por otra parte, podrían facilitar el posicionamiento de pacientes de bajo riesgo de ulceración.
► Los clínicos y pacientes debieran sopesar los beneficios y los potenciales riesgos para tomar la decisión final.
El Panel de Expertos analizó y debatió cada uno de las preguntas de la “Tabla de la evidencia a la decisión”, considerando tanto la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes. Una vez consensuada la postura del panel respecto a las preguntas, emitieron un juicio seleccionando la opción de respuesta que mejor representaba la opinión del conjunto (destacada con color). Finalmente cuando el panel emitió su juicio sobre todas las preguntas, se emitió la recomendación.
A continuación se presenta la “Tabla de la evidencia a la decisión” con el resumen de los juicios, la evidencia de investigación evaluada, consideraciones adicionales y comentarios planteados por el panel.
1.- ¿El problema es una prioridad?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
El problema ha sido definido como prioritario en el marco de las Garantías Explícitas en Salud (GES), régimen integral de salud que prioriza un grupo de patologías o problemas de salud, garantizando el acceso a tratamiento oportuno y de calidad.
2.- ¿Qué tan significativos son los efectos deseables anticipados?
| Trivial | Pequeño | Moderado | Grande | Varía | No lo sé |
|---|
Moderados: El equipo elaborador de la Guía estimó que los efectos deseables de «usar cojín antiescaras de celdas de aire» en comparación a «usar cojín viscoelástico» son moderados, considerando la evidencia, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud.
Consideraciones Adicionales
El desenlace evaluado en el estudio incluido hace referencia al tratamiento de las úlceras por presión.
No existiendo estudios que evaluen esta intervención desde la perspectiva de la prevención de úlceras, el panel señala que el cojin antiescaras con celdas de aire tiene efectos deseables superiores al viscoelástico en su incidencia.
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
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Cojín antiescaras de celdas de aire comparado con cojín antiescaras viscoelástico. |
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Población |
Personas de 65 años y más con limitación en la movilidad. |
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Intervención |
Cojín antiescaras viscoelástico. |
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Comparación |
Cojín antiescaras de celdas de aire. |
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Desenlaces |
Efecto relativo (IC 95%) — Estudios/ personas |
Efecto absoluto estimado* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
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|
Cojín antiescaras viscoelástico |
Cojín antiescaras con celdas de aire |
Diferencia (IC 95%) |
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|
Incidencia de úlceras por presión |
No se identificaron estudios que evaluaran este desenlace en la comparación de interés. |
— |
— |
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|
Número de úlceras por presión completamente curadas. |
RR 2,12 (0,64 a 7,00) — 1 ensayo [104] / 25 personas |
214 por 1000 |
454 por 1000 |
Diferencia: 240 más (77 menos a 1000 más) |
⊕◯◯◯1,2 Muy baja |
El uso de un colchón antiescaras con celdas de aire, podría ser más efectivo comparado con un colchón antiescaras viscoelástico en el tratamiento de las úlceras. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
IC 95%: Intervalo de confianza del 95%.
RR: Riesgo relativo.
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* El riesgo CON colchón antiescaras con celdas de aire está basado en el riesgo del grupo control en los estudios. El riesgo CON cojín antiescaras viscoelástico (y su intervalo de confianza) está calculado a partir del efecto relativo (y su intervalo de confianza).
1 Se disminuyó un nivel de certeza de evidencia por riesgo de sesgo, ya que en los ensayos no estaba clara la generación de secuencia de aleatorización, ocultamiento de ésta y no estaba claro si fue ciego.
2 Se disminuyó dos niveles de certeza de evidencia por imprecisión ya que cada extremo del intervalo de confianza conlleva una decisión diferente. Además, el ensayo incluidos presentan un número reducido de eventos y de pacientes.
Fecha de elaboración de la tabla: Diciembre, 2018.
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Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
3.- ¿Qué tan significativos son los efectos indeseables anticipados?
| Grande | Moderado | Pequeño | Trivial | Varía | No lo sé |
|---|
No lo sé: El equipo elaborador de la Guía consideró que no contaba con suficiente información para emitir un juicio respecto a la significancia de los efectos indeseables de «usar cojín antiescaras de celdas de aire» en comparación a «usar cojín viscoelástico».
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
|
Cojín antiescaras de celdas de aire comparado con cojín antiescaras viscoelástico. |
||||||
|
Población |
Personas de 65 años y más con limitación en la movilidad. |
|||||
|
Intervención |
Cojín antiescaras viscoelástico. |
|||||
|
Comparación |
Cojín antiescaras de celdas de aire. |
|||||
|
Desenlaces |
Efecto relativo (IC 95%) — Estudios/ personas |
Efecto absoluto estimado* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
||
|
Cojín antiescaras viscoelástico |
Cojín antiescaras con celdas de aire |
Diferencia (IC 95%) |
||||
|
Incidencia de úlceras por presión |
No se identificaron estudios que evaluaran este desenlace en la comparación de interés. |
— |
— |
|||
|
Número de úlceras por presión completamente curadas. |
RR 2,12 (0,64 a 7,00) — 1 ensayo [104] / 25 personas |
214 por 1000 |
454 por 1000 |
Diferencia: 240 más (77 menos a 1000 más) |
⊕◯◯◯1,2 Muy baja |
El uso de un colchón antiescaras con celdas de aire, podría ser más efectivo comparado con un colchón antiescaras viscoelástico en el tratamiento de las úlceras. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
IC 95%: Intervalo de confianza del 95%.
RR: Riesgo relativo.
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* El riesgo CON colchón antiescaras con celdas de aire está basado en el riesgo del grupo control en los estudios. El riesgo CON cojín antiescaras viscoelástico (y su intervalo de confianza) está calculado a partir del efecto relativo (y su intervalo de confianza).
1 Se disminuyó un nivel de certeza de evidencia por riesgo de sesgo, ya que en los ensayos no estaba clara la generación de secuencia de aleatorización, ocultamiento de ésta y no estaba claro si fue ciego.
2 Se disminuyó dos niveles de certeza de evidencia por imprecisión ya que cada extremo del intervalo de confianza conlleva una decisión diferente. Además, el ensayo incluidos presentan un número reducido de eventos y de pacientes.
Fecha de elaboración de la tabla: Diciembre, 2018.
Referencias
1. Serraes B, van Leen M, Schols J, Van Hecke A, Verhaeghe S, Beeckman D. Prevention of pressure ulcers with a static air support surface: A systematic review. International wound journal. 2018;15(3):333-343.
2. Shi C, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention: A network meta-analysis. PloS one. 2018;13(2):e0192707.
3. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA : the journal of the American Medical Association. 2006;296(8):974-84.
4. McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Middleton V, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews. 2015;9(9):CD001735.
5. Vanderwee K, Grypdonck M, Defloor T. Alternating pressure air mattresses as prevention for pressure ulcers: a literature review. International journal of nursing studies. 2008;45(5):784-801.
6. McInnes E, Jammali-Blasi A, Bell-Syer S, Dumville J, Cullum N. Preventing pressure ulcers: Are pressure-redistributing support surfaces effective? A Cochrane systematic review and meta-analysis. International journal of nursing studies. 2012;49(3):345-59.
7. Nicosia G, Gliatta AE, Woodbury MG, Houghton PE. The effect of pressure-relieving surfaces on the prevention of heel ulcers in a variety of settings: a meta-analysis. International wound journal. 2007;4(3):197-207.
8. Huang HY, Chen HL, Xu XJ. Pressure-redistribution Surfaces for Prevention of Surgery-related Pressure Ulcers: A Meta-Analysis. Ostomy/wound management. 2013;59(4):36-48.
9. Health Quality Ontario. Pressure ulcer prevention: an evidence-based analysis. Ont Health Technol Assess Ser. 2009;9(2):1-104.
10. Andersen KE, Jensen O, Kvorning SA, Bach E. Decubitus prophylaxis: a prospective trial on the efficiency of alternating-pressure air-mattresses and water-mattresses. Acta dermato-venereologica. 1983;63(3):227-30.
11. Aronovitch SA, Wilber M, Slezak S, Martin T, Utter D. A comparative study of an alternating air mattress for the prevention of pressure ulcers in surgical patients. Ostomy/wound management. 1999;45(3):34-40, 42-4.
12. Bennett RG, Baran PJ, DeVone LV, Bacetti H, Kristo B, Tayback M, Greenough WB. Low airloss hydrotherapy versus standard care for incontinent hospitalized patients. Journal of the American Geriatrics Society. 1998;46(5):569-76.
13. Bliss MR, McLaren R, Exton-Smith AN. Preventing pressure sores in hospital: controlled trial of a large-celled ripple mattress. British medical journal. 1967;1(5537):394-7.
14. Bliss MR. Preventing pressure sores in elderly patients: a comparison of seven mattress overlays. Age and ageing. 1995;24(4):297-302.
15. Brienza D, Kelsey S, Karg P, Allegretti A, Olson M, Schmeler M, Zanca J, Geyer MJ, Kusturiss M, Holm M. A randomized clinical trial on preventing pressure ulcers with wheelchair seat cushions. Journal of the American Geriatrics Society. 2010;58(12):2308-14.
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17. Cavicchioli A, Carella G. Clinical effectiveness of a low-tech versus high-tech pressure-redistributing mattress. Journal of wound care. 2007;16(7):285-9.
18. Chalian AA, Kagan SH. Backside first in head and neck surgery?: preventing pressure ulcers in extended length surgeries. Head & neck. 2001;23(1):25-8.
19. Chaloner, D., Cave, J.. Should weaker study designs ever be preferred over randomised controlled trials. Journal of Tissue Viability. 2000.
20. Chunping Ji, Jinxia Dong, Chun Li.. Comparison of effectiveness of preventing pressure sore by three different mattresses. Chinese Nursing Research. 2011;
21. Cobb, G.A., Yoder, L.H., Warren, J.B.. Pressure Ulcers: Patient Outcomes on a KinAir Bed or EHOB Waffle Mattress. 1997;
22. Collier ME. Pressure-reducing mattresses. Journal of wound care. 1996;5(5):207-11.
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2. Shi C, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention: A network meta-analysis. PloS one. 2018;13(2):e0192707.
3. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA : the journal of the American Medical Association. 2006;296(8):974-84.
4. McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Middleton V, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews. 2015;9(9):CD001735.
5. Vanderwee K, Grypdonck M, Defloor T. Alternating pressure air mattresses as prevention for pressure ulcers: a literature review. International journal of nursing studies. 2008;45(5):784-801.
6. McInnes E, Jammali-Blasi A, Bell-Syer S, Dumville J, Cullum N. Preventing pressure ulcers: Are pressure-redistributing support surfaces effective? A Cochrane systematic review and meta-analysis. International journal of nursing studies. 2012;49(3):345-59.
7. Nicosia G, Gliatta AE, Woodbury MG, Houghton PE. The effect of pressure-relieving surfaces on the prevention of heel ulcers in a variety of settings: a meta-analysis. International wound journal. 2007;4(3):197-207.
8. Huang HY, Chen HL, Xu XJ. Pressure-redistribution Surfaces for Prevention of Surgery-related Pressure Ulcers: A Meta-Analysis. Ostomy/wound management. 2013;59(4):36-48.
9. Health Quality Ontario. Pressure ulcer prevention: an evidence-based analysis. Ont Health Technol Assess Ser. 2009;9(2):1-104.
10. Andersen KE, Jensen O, Kvorning SA, Bach E. Decubitus prophylaxis: a prospective trial on the efficiency of alternating-pressure air-mattresses and water-mattresses. Acta dermato-venereologica. 1983;63(3):227-30.
11. Aronovitch SA, Wilber M, Slezak S, Martin T, Utter D. A comparative study of an alternating air mattress for the prevention of pressure ulcers in surgical patients. Ostomy/wound management. 1999;45(3):34-40, 42-4.
12. Bennett RG, Baran PJ, DeVone LV, Bacetti H, Kristo B, Tayback M, Greenough WB. Low airloss hydrotherapy versus standard care for incontinent hospitalized patients. Journal of the American Geriatrics Society. 1998;46(5):569-76.
13. Bliss MR, McLaren R, Exton-Smith AN. Preventing pressure sores in hospital: controlled trial of a large-celled ripple mattress. British medical journal. 1967;1(5537):394-7.
14. Bliss MR. Preventing pressure sores in elderly patients: a comparison of seven mattress overlays. Age and ageing. 1995;24(4):297-302.
15. Brienza D, Kelsey S, Karg P, Allegretti A, Olson M, Schmeler M, Zanca J, Geyer MJ, Kusturiss M, Holm M. A randomized clinical trial on preventing pressure ulcers with wheelchair seat cushions. Journal of the American Geriatrics Society. 2010;58(12):2308-14.
16. Cadue JF, Karolewicz S, Tardy C, Barrault C, Robert R, Pourrat O. [Prevention of heel pressure sores with a foam body-support device. A randomized controlled trial in a medical intensive care unit]. Presse médicale (Paris, France : 1983). 2008;37(1 Pt 1):30-6.
17. Cavicchioli A, Carella G. Clinical effectiveness of a low-tech versus high-tech pressure-redistributing mattress. Journal of wound care. 2007;16(7):285-9.
18. Chalian AA, Kagan SH. Backside first in head and neck surgery?: preventing pressure ulcers in extended length surgeries. Head & neck. 2001;23(1):25-8.
19. Chaloner, D., Cave, J.. Should weaker study designs ever be preferred over randomised controlled trials. Journal of Tissue Viability. 2000.
20. Chunping Ji, Jinxia Dong, Chun Li.. Comparison of effectiveness of preventing pressure sore by three different mattresses. Chinese Nursing Research. 2011;
21. Cobb, G.A., Yoder, L.H., Warren, J.B.. Pressure Ulcers: Patient Outcomes on a KinAir Bed or EHOB Waffle Mattress. 1997;
22. Collier ME. Pressure-reducing mattresses. Journal of wound care. 1996;5(5):207-11.
23. Conine TA, Daechsel D, Choi AK, Lau MS. Costs and acceptability of two special overlays for the prevention of pressure sores. Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses. 1990;15(3):133-7.
24. Conine TA, Hershler C, Daechsel D, Peel C, Pearson A. Pressure ulcer prophylaxis in elderly patients using polyurethane foam or Jay wheelchair cushions. International journal of rehabilitation research. Internationale Zeitschrift für Rehabilitationsforschung. Revue internationale de recherches de réadaptation. 1994;17(2):123-37.
25. Conine, Tali A., Daechsel, Dawn, Hershler, Cecil. Pressure Sore Prophylaxis in Elderly Patients Using Slab Foam or Customized Contoured Foam Wheelchair Cushions. OTJR: Occupation, Participation and Health. 1993;13(2):101-116.
26. Cooper PJ, Gray DG, Mollison J. A randomised controlled trial of two pressure-reducing surfaces. Journal of wound care. 1998;7(8):374-6.
27. Daechsel D, Conine TA. Special mattresses: effectiveness in preventing decubitus ulcers in chronic neurologic patients. Archives of physical medicine and rehabilitation. 1985;66(4):246-8.
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Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
4.- ¿Cuál es la certeza general de la evidencia sobre efectos?
| Muy baja | Baja | Moderada | Alta | Ningún estudio incluido |
|---|
Muy Baja: Existe considerable incertidumbre respecto del efecto de «usar cojín antiescaras de celdas de aire» en comparación a «usar cojín viscoelástico».
Evidencia de investigación
|
Desenlaces |
Importancia |
Certeza de la evidencia |
|
Incidencia de úlceras por presión |
no reportado |
– |
|
Úlceras por presión completamente curadas |
CRÍTICO |
⨁◯◯◯ |
a. Se disminuyó un nivel de certeza de evidencia por riesgo de sesgo, ya que en los ensayos no estaba clara la generación de secuencia de aleatorización, ocultamiento de ésta y no estaba claro si fue ciego.
b. Se disminuyó dos niveles de certeza de evidencia por imprecisión ya que cada extremo del intervalo de confianza conlleva una decisión diferente. Además, el ensayo incluidos presentan un número reducido de eventos y de personas.
5.- ¿Hay incertidumbre importante o variabilidad sobre qué tanto valora la gente los desenlaces principales?
| Incertidumbre o variabilidad importantes | Posiblemente hay incertidumbre o variabilidad importantes | Probablemente no hay incertidumbre ni variabilidad importantes | No hay variabilidad o incertidumbre importante |
|---|
Incertidumbre o variabilidad importantes: En función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud, el equipo elaborador de la Guía consideró que existe incertidumbre o variabilidad importante respecto a lo que escogería una persona informada de los efectos deseables e indeseables de «usar cojín antiescaras de celdas de aire» y «usar cojín viscoelástico».
Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de valores y preferencias de los pacientes
6.- El balance entre efectos deseables e indeseables favorece la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | No lo sé |
|---|
Probablemente favorece la intervención: Considerando que la intervención es «usar cojín antiescaras de celdas de aire» y la comparación es «usar cojín viscoelástico», el equipo elaborador de la Guía opinó que el balance entre efectos deseables e indeseables probablemente favorece «usar cojín antiescaras de celdas de aire».
7.- ¿Qué tan grandes son los recursos necesarios (costos)?
| Costos extensos | Costos moderados | Costos y ahorros despreciables | Ahorros moderados | Ahorros extensos | Varía | No lo sé |
|---|
Costos y ahorros despreciables: El equipo elaborador de la Guía consideró que los costos y ahorros de «uso de bastón con un punto de apoyo» son despreciables si se compara con «uso de bastón con más puntos de apoyos», en función de los antecedentes, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
Tabla. Precios referenciales*
| Ítem | Usar cojín antiescaras de celdas de aire | Usar cojín antiescaras viscoelástico |
| COJÍN ANTIESCARAS CELDAS DE AIRE | $ 140.4003– $182.5203 | —– |
| —– | ||
| COJÍN ANTIESCARAS CELDAS DE AIRE, BAJO PERFIL, ANCHO ENTRE 35 Y 45 CM CONFORM | $1.904.001 | |
| COJÍN ANTIESCARAS ANTIMICOBIANO Y PIRORETARDANTE | $2.485.911 | —– |
| COJIN ANTIESCARAS VISCOELÁSTICO (42 cm de ancho) | —– | $47.6001-$56.6303 |
| COJÍN ANTIESCARAS | —– | $302.972 |
| COJÍN ANTIESCARAS VISCOELÁSTICO | —– | $581.003 |
| Total | Rango: | Rango: |
| $46.3511-$248.5911 | $ 30.2972-58.1003 |
*El porcentaje de cobertura del seguro de salud sobre el precio de la(s) prestación (es) sanitaria(s), dependerá del tipo de seguro de cada paciente.
Referencia
1. Mercado Público, 2018.
2. EVC, 2015.
3. Arancel PPV, 2018.
Búsqueda y Síntesis de Evidencia
Búsqueda de costos
8.- ¿La costo-efectividad de la intervención beneficia la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | Ningún estudio incluido |
|---|
Probablemente favorece la intervención: Considerando que la intervención es «usar cojín antiescaras de celdas de aire» y la comparación es «usar cojín viscoelástico», el equipo elaborador de la Guía opinó que probablemente la alternativa más costo-efectiva es «usar cojín antiescaras de celdas de aire».
Consideraciones Adicionales
El panel realiza su juicio destacando que la utilización del cojín antiescaras de celdas de aire permite reducción de días cama y los costos asociados al tratamiento de las úlceras por presión (curaciones avanzadas, antibióticos, entre otras).
Evidencia de investigación
No se realizó búsqueda de estudios que abordaran costo-efectividad, debido a que esta búsqueda se realiza sólo cuando la intervención es considerada un tratamiento o diagnóstico de alto costo (1).
1. Anual $2.418.399 y Mensual $201.533. Ministerio de Salud. Decreto 80: Determinar umbral nacional de costo anual al que se refiere el artículo 6° de la Ley 20.850 [Internet]. Santiago; 2015 Nov.
9.- ¿Cuál sería el impacto en equidad en salud?
| Reducido | Probablemente reducido | Probablemente ningún impacto | Probablemente aumentado | Aumentado | Varía | No lo sé |
|---|
Probablemente reducida: El equipo elaborador de la Guía consideró que la equidad en salud se probablemente se reduciría si se recomendase «usar cojín antiescaras de celdas de aire», dado que identificó grupos o contextos que actualmente tiene barreras de acceso importantes, ya sea en términos económicos, geográficos u otros.
Consideraciones Adicionales
El panel menciona que existen algunos servicios de salud del país que costean la adquisición de cojín de celdas de aire.
10.- ¿La intervención es aceptable para las partes interesadas?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Probablemente sí: El equipo elaborador de la Guía consideró que «usar cojín antiescaras de celdas de aire» probablemente SÍ es aceptable para las partes interesadas (profesionales de la salud, gestores de centros de salud, directivos de centros de salud, pacientes, cuidadores, seguros de salud, otros).
11.- ¿Es factible implementar la intervención?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Sí: El equipo elaborador de la Guía consideró que «usar cojín antiescaras de celdas de aire» SÍ es factible implementar, contemplando la capacidad de la red asistencial, los recursos humanos disponibles a nivel país, recursos financieros, etc.