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 colchón antiescaras con celdas de aire por sobre colchón antiescaras con presión alternante.
Comentarios del panel:
► El colchón con celdas de aire podría disminuir el riesgo de úlceras por presión, además de favorecer su cicatrización.
► El uso del colchón con celdas de aires es sólo un componente más del manejo integral para la prevención de úlceras por presión, es importante educar en los cambios regulares de posición.
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.
| 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.
| Trivial | Pequeño | Moderado | Grande | Varía | No lo sé |
|---|
Pequeños: El equipo elaborador de la Guía estimó que los efectos deseables de «usar colchón antiescaras con celdas de aire » en comparación a «usar colchón antiescaras con presión alternante» son pequeños, considerando la evidencia, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud.
Consideraciones Adicionales
No existiendo estudios que evalúen esta intervención desde la perspectiva de la prevención de úlceras, el panel señala que el colchón antiescaras con celdas de aire de presión pasiva tiene efectos deseables superiores al cobertor de presión alternante de celdas de aire en su incidencia.
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
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Colchón antiescaras con celdas de aire comparado con colchón antiescaras con presión alternante. |
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Población |
Personas de 65 años y más con limitación en la movilidad. |
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Intervención |
Colchón antiescaras con celdas de aire. |
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Comparación |
Colchón antiescaras con presión alternante. |
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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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Colchón antiescaras con presión alternante |
Colchón antiescaras con celdas de aire |
Diferencia (IC 95%) |
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Incidencia de úlceras por presión |
RR 0,58 (0,12 a 2,90) — 2 ensayos [55, 83] / 1114 personas |
19 por 1000 |
11 por 1000 |
Diferencia: 8 menos (17 menos a 36 más) |
⊕◯◯◯1,2,3 Muy baja |
El uso de un colchón antiescaras con celdas de aire podría ser efectivo en disminuir la incidencia de úlceras por presión en comparación con colchón antiescaras con presión alternante. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
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Riesgo de desarrollar úlceras por presión ** |
RR 0,98 — 1 ensayo [55] /1074 personas |
316 por 1000 |
310 por 1000 |
Diferencia: 6 menos (57 menos a 57 más) |
⊕◯◯◯1,2 Muy baja |
El uso de un colchón antiescaras con celdas de aire podría ser efectivo en disminuir el riesgo de desarrollar úlceras por presión comparado con colchón antiescaras con presión alternante. 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 colchón antiescaras con presión alternante (y su intervalo de confianza) está calculado a partir del efecto relativo (y su intervalo de confianza).
** El riesgo de úlceras por presión fue medido de acuerdo a la Escala de Braden. Los pacientes que obtuvieron un puntaje menor a 16 en esta escala, fueron considerados en riesgo.
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, ambos ensayos incluidos presentan un número reducido de eventos.
3 Se disminuyó un nivel de certeza de evidencia por inconsistencia, ya que cada ensayo presenta diferentes conclusiones.
Fecha de elaboración de la tabla: Diciembre, 2018.
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117. Gunningberg L, Lindholm C, Carlsson M, Sjödén PO. Implementation of risk assessment and classification of pressure ulcers as quality indicators for patients with hip fractures. Journal of clinical nursing. 1999;8(4):396-406.
Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
| 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 colchón antiescaras con celdas de aire » en comparación a «usar colchón antiescaras con presión alternante».
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
|
Colchón antiescaras con celdas de aire comparado con colchón antiescaras con presión alternante. |
||||||
|
Población |
Personas de 65 años y más con limitación en la movilidad. |
|||||
|
Intervención |
Colchón antiescaras con celdas de aire. |
|||||
|
Comparación |
Colchón antiescaras con presión alternante. |
|||||
|
Desenlaces |
Efecto relativo (IC 95%) — Estudios/ personas |
Efecto absoluto estimado* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
||
|
Colchón antiescaras con presión alternante |
Colchón antiescaras con celdas de aire |
Diferencia (IC 95%) |
||||
|
Incidencia de úlceras por presión |
RR 0,58 (0,12 a 2,90) — 2 ensayos [55, 83] / 1114 personas |
19 por 1000 |
11 por 1000 |
Diferencia: 8 menos (17 menos a 36 más) |
⊕◯◯◯1,2,3 Muy baja |
El uso de un colchón antiescaras con celdas de aire podría ser efectivo en disminuir la incidencia de úlceras por presión en comparación con colchón antiescaras con presión alternante. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
|
Riesgo de desarrollar úlceras por presión ** |
RR 0,98 — 1 ensayo [55] /1074 personas |
316 por 1000 |
310 por 1000 |
Diferencia: 6 menos (57 menos a 57 más) |
⊕◯◯◯1,2 Muy baja |
El uso de un colchón antiescaras con celdas de aire podría ser efectivo en disminuir el riesgo de desarrollar úlceras por presión comparado con colchón antiescaras con presión alternante. 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 colchón antiescaras con presión alternante (y su intervalo de confianza) está calculado a partir del efecto relativo (y su intervalo de confianza).
** El riesgo de úlceras por presión fue medido de acuerdo a la Escala de Braden. Los pacientes que obtuvieron un puntaje menor a 16 en esta escala, fueron considerados en riesgo.
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, ambos ensayos incluidos presentan un número reducido de eventos.
3 Se disminuyó un nivel de certeza de evidencia por inconsistencia, ya que cada ensayo presenta diferentes conclusiones.
Fecha de elaboración de la tabla: Diciembre, 2018.
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117. Gunningberg L, Lindholm C, Carlsson M, Sjödén PO. Implementation of risk assessment and classification of pressure ulcers as quality indicators for patients with hip fractures. Journal of clinical nursing. 1999;8(4):396-406.
Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
| Muy baja | Baja | Moderada | Alta | Ningún estudio incluido |
|---|
Muy Baja: Existe considerable incertidumbre respecto del efecto de «usar colchón antiescaras con celdas de aire » en comparación a «usar colchón antiescaras con presión alternante».
Evidencia de investigación
|
Desenlaces |
Importancia |
Certeza de la evidencia |
|
Úlcera por presión |
CRÍTICO |
⨁◯◯◯ |
|
Riesgo de desarrollar úlceras por presión |
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, ambos ensayos incluidos presentan un número reducido de eventos.
c. Se disminuyó un nivel de certeza de evidencia por inconsistencia, ya que cada ensayo presenta diferentes conclusiones.
d. Se disminuyó un nivel de certeza de evidencia por riesgo de sesgo, ya que en el ensayo no estaba clara la generación de secuencia de aleatorización, ocultamiento de ésta y no estaba claro si fue ciego
| Incertidumbre o variabilidad importantes | Posiblemente hay incertidumbre o variabilidad importantes | Probablemente no hay incertidumbre ni variabilidad importantes | No hay variabilidad o incertidumbre importante |
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Probablemente no hay incertidumbre ni 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 probablemente no hay incertidumbre o ni variabilidad importante respecto a lo que escogería una persona informada de los efectos deseables e indeseables de «usar colchón antiescaras con celdas de aire » y «usar colchón antiescaras con presión alternante». La mayoría de las personas escogerían usar colchón antiescaras con celdas de aire.
Evidencia de investigación
No se identificaron estudios que respondieran directamente la pregunta según la perspectiva de valores y preferencias de los pacientes.
Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de valores y preferencias de los pacientes
| 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 |
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Probablemente favorece la intervención: Considerando que la intervención es «usar colchón antiescaras con celdas de aire » y la comparación es «usar colchón antiescaras con presión alternante», el equipo elaborador de la Guía opinó que el balance entre efectos deseables e indeseables probablemente favorece » usar colchón antiescaras con celdas de aire «.
| 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 «usar colchón antiescaras con celdas de aire » son despreciables si se compara con «usar colchón antiescaras con presión alternante», en función de los antecedentes, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
Tabla. Precios referenciales*
| Ítem | Usar colchón antiescaras con presión alternante | Usar colchón antiescaras con celdas de aire |
| Cochón antiescaras con sistema de flujo alternante | $479.001 | —– |
| Colchón antiescaras de presión alternante | ||
| $450.001 | —– | |
| Colchón antiescaras de flujo alternante con motor | ||
| $466.651 | —– | |
| Colchón antiescaras con motor, de PVC, con burbujas que se inflan y desinflan en ciclos alternos | ||
| $339.152 | —– | |
| Colchón antiescaras de celdas | —– | $1.410.152 |
| Colchón Antiescaras de Flotación Seca de Tres Secciones de aire multicelular | —– | $2.141.402 |
| Total | Rango: $33.915-$47.900 | Rango: $141.015-$214.140 |
*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.
Referencias
1. Mercado privado
2. Mercado público
Búsqueda y Síntesis de Evidencia
Búsqueda de costos
| 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 |
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Probablemente favorece la intervención: Considerando que la intervención es «usar colchón antiescaras con celdas de aire » y la comparación es «usar colchón antiescaras con presión alternante», el equipo elaborador de la Guía opinó que probablemente la alternativa más costo-efectiva es «usar colchón antiescaras con celdas de aire «.
Consideraciones Adicionales
El panel realiza el juicio ya que al existir menor incidencia de úlceras por presión con el uso de colchón antiescaras con celdas de aires hay menos costos sanitarios asociados.
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.
| Reducido | Probablemente reducido | Probablemente ningún impacto | Probablemente aumentado | Aumentado | Varía | No lo sé |
|---|
Probablemente ningún impacto: El equipo elaborador de la Guía consideró que probablemente no tendría ningún impacto en la equidad en salud si se recomendase «usar colchón antiescaras con celdas de aire «, dado que identificó grupos o contextos que actualmente tiene barreras de acceso importantes, ya sea en términos económicos, geográficos u otros.
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Probablemente sí: El equipo elaborador de la Guía consideró que «usar colchón antiescaras con 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).
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Probablemente sí: El equipo elaborador de la Guía consideró que «usar colchón antiescaras con celdas de aire » probablemente SÍ es factible implementar, contemplando la capacidad de la red asistencial, los recursos humanos disponibles a nivel país, recursos financieros, etc.