Trends in hospitalizations for primary care sensitive conditions following the implementation of Family Health Teams in Belo Horizonte, Brazil

Disease awareness and healthcare utilization in rural South Africa: a comparative analysis of HIV and diabetes in the HAALSI cohort

BACKGROUND

Studies from rural South Africa indicate that people living with HIV (PLHIV) may have better health outcomes than those without, potentially due to the frequent healthcare visits necessitated by infection. Here, we examined the association between HIV status and healthcare utilization, using diabetes as an illustrative comparator of another high-burden, healthcare-intensive disease.

METHODS

Our exposure of interest was awareness of positive disease status for both HIV and diabetes. We identified 742 individuals who were HIV-positive and aware of their status and 305 who had diabetes and were aware of their status. HIV-positive status was further grouped by viral suppression. For each disease, we estimated the association with (1) other comorbid, chronic conditions, (2) health facility visits, (3) household-level healthcare expenditure, and (4) per-visit healthcare expenditure. We used log-binomial regression models to estimate prevalence ratios for co-morbid chronic conditions. Linear regression models were used for all other outcomes.

RESULTS

Virally suppressed PLHIV had decreased prevalence of chronic conditions, increased public clinic visits [β = 0.59, 95% CI: 0.5, 0.7], and reduced per-visit private clinic spending [β = -60, 95% CI: -83, -6] compared to those without HIV. No differences were observed in hospitalizations and per-visit spending at hospitals and public clinics between virally suppressed PLHIV and non-PLHIV. Conversely, diabetic individuals had increased prevalence of chronic conditions, increased visits across facility types, increased household-level expenditures (β = 88 R, 95% CI: 29, 154), per-visit hospital spending (β = 54 R, 95% CI: 7, 155), and per-visit public clinic spending (β = 31 R, 95% CI: 2, 74) compared to those without diabetes.

CONCLUSIONS

Our results suggest that older adult PLHIV may visit public clinics more often than their HIV-negative counterparts but spend similarly on a per-visit basis. This provides preliminary evidence that the positive health outcomes observed among PLHIV in rural South Africa may be explained by different healthcare engagement patterns. Through our illustrative comparison between PLHIV and diabetics, we show that shifting disease burdens towards chronic and historically underfunded diseases, like diabetes, may be changing the landscape of health expenditure inequities.

The impact of residency training in family medicine on hospital admissions due to Ambulatory-care Sensitive Conditions in Rio de Janeiro

Lack of skilled human resources in primary care remains a major concern for policymakers in low- and middle-income countries. There is little evidence supporting the impact of residency training in family medicine in the quality of care, and it perpetuates misconceptions among policymakers that the provision of primary care can be easily done by any physician without special training. This article compares the risk of patients being hospitalized due to Ambulatory care sensitive conditions and the odds of having follow-up visits in primary care after hospital discharge, according to the type of their medical provider: (1) Generalists (reference), (2) Family physicians; and, (3) patients with no consultations prior to the event. Multilevel multivariate binomial regression models estimated the relative risks of a patient being hospitalized in a given month and the relative risks for the occurrence of a follow-up visit in primary care in a retrospective cohort of 636.640 patients between January 2013 and July 2018 in Rio de Janeiro. For all 14 conditions, there was a higher risk of hospitalization when patients had no consultation in primary care prior to the event. Except for Ear, Nose and Throat infections, patients seen by family physicians had a lower risk of being hospitalized, compared to patients seen by Generalists. Follow-up visits were more likely to happen among patients treated by family physicians for almost every condition analyzed. With two years of training in family medicine, Family physicians can reduce the risk of their patients being hospitalized and increase the likelihood of those patients having a follow-up consultation in primary care. Investments in residency training in family medicine should be made to fix the shortage of skilled physicians in primary care, reduce hospitalizations and improve quality and continuity of care.

The Brazilian Family Health Strategy and adult health: Evidence from individual and local data for metropolitan areas

Previous studies have found that the expansion of primary health care in Brazil following the country-wide family health strategy (ESF), one of the largest primary care programs in the world, has improved health outcomes. However, these studies have relied either on aggregate data or on limited individual data, with no fine-grained information available concerning household participation in the ESF or local supply of ESF services, which represent crucial aspects for analytical and policy purposes. This study analyzes the relationship between the ESF and health outcomes for the adult population in metropolitan areas in Brazil. We investigate this relationship through two linked dimensions of the ESF: the program's local supply of health teams and ESF household registration. In contrast with previous studies focusing on comparisons between certain definitions of "treated" versus "nontreated" populations, our results indicate that the local density of health teams is important to the observed effects of the ESF on adult health. We also find evidence consistent with the presence of positive primary health care spillovers to people not registered with the ESF. However, current ESF coverage levels in metropolitan areas have limited ability to address prevailing health inequalities. Our analysis suggests that the local intensity of ESF coverage should be a key consideration for evaluations and policy efforts related to future ESF expansion.

Number of health care teams and hospitalizations due to primary care sensitive conditions

This study aimed to analyze the correlation between the number of health care teams of the Family Health Strategy (FHS) and the number of hospitalizations due to primary care sensitive conditions (HPCSC) taking into account rates, costs and hospital days in a large municipality of the state of Minas Gerais, Brazil, between 2010 and 2019. We performed an ecological time series correlation study on HPCSC of patients hospitalized by the public health system. Data were obtained from the Hospital Information System of the IT Department of the Public Health System (DATASUS) and from the Primary Care Information and Management System. The correlation analysis was performed based on the number, gross and standardized rates, percentages, costs and hospital days of HPCSC and health care coverage (average number of teams) using Spearman's correlation coefficient at a significance level of 5% (p < 0.05). No satisfactory correlation was found in the entire period between the increase in the number of health care teams and HPCSC (except for the standardized hospitalization rate). However, during the period in which the FHS coverage of the population was greater than 70%, all correlations were inversely proportional and statistically significant.

Trend of hospitalizations for ambulatory care sensitive conditions and related aspects in Sergipe, 2010 to 2019

Objective: To analyze the trend of hospitalization rates for ambulatory care-sensitive conditions (HACSC) in Sergipe and its seven health regions between 2010 and 2019, correlating with financial investments in health and primary care, strategy coverage of family health, and the number of hospital beds. Methods: This is an ecological time-series study trend with secondary data from the Ministry of Health. The trend verification was done by segmented linear analysis and the correlation between the variables by Spearman's correlation. Results: HACSC in the state of Sergipe showed a trend towards stability. In the Nossa Senhora do Socorro region, an increasing rate trend was identified from 2010 to 2017 and a non-significant decreasing trend from 2017 to 2019, with a negative correlation with per capita investment in PHC. The Itabaiana region showed a trend of reduction in rates from 2010 to 2012, followed by a trend of growth in rates from 2012 to 2020, with no significant correlation with any of the variables. Conclusions: Monitoring HACSC rates and understanding their multifactorial influence are essential since this indicator is helpful in local situational diagnosis and contributes to planning actions.

Number of health care teams and hospitalizations due to primary care sensitive conditions

Abstract This study aimed to analyze the correlation between the number of health care teams of the Family Health Strategy (FHS) and the number of hospitalizations due to primary care sensitive conditions (HPCSC) taking into account rates, costs and hospital days in a large municipality of the state of Minas Gerais, Brazil, between 2010 and 2019. We performed an ecological time series correlation study on HPCSC of patients hospitalized by the public health system. Data were obtained from the Hospital Information System of the IT Department of the Public Health System (DATASUS) and from the Primary Care Information and Management System. The correlation analysis was performed based on the number, gross and standardized rates, percentages, costs and hospital days of HPCSC and health care coverage (average number of teams) using Spearman’s correlation coefficient at a significance level of 5% (p < 0.05). No satisfactory correlation was found in the entire period between the increase in the number of health care teams and HPCSC (except for the standardized hospitalization rate). However, during the period in which the FHS coverage of the population was greater than 70%, all correlations were inversely proportional and statistically significant.

Use of Health Services and Family Health Strategy Households Population Coverage in Brazil

The objective of this study is to describe the profile of use of primary health care services, estimated by the PNS, of the population living in households registered and not registered with the Famly Health Strategy - FHS, in the years 2013 and 2019. Cross-sectional study carried out using microdata from national health surveys 2013 and 2019. The sample originated from a master sample, consisting of a set of units from selected areas in a register..The variables sex, age, skin color, income, education, self-perceived health, home registered with the FHS, medical care in the last year, type of service you seek when you are ill were selected. The dependent variables were use of health services and use of public health services. The dependent and independent variables were described with the respective confidence interval and adjusted logistic regression was performed for each outcome analyzed. In public health services, lower income, have chronic diseases (arterial hypertension or high cholesterol), be pregnant, and having a bad self-perception of health were associated with used more health services in both periods. Living in registered households was associated with more used health services (public or private). The family health strategy is an important strategy for expanding access equally.

[The impact of primary healthcare and the reduction of primary health care-sensitive hospital admissions]

This study aimed to analyze the association between quality of primary healthcare (PHC) in Brazilian municipalities (counties) and the number of hospitalizations due to primary healthcare-sensitive conditions. This was an ecological study with analysis of nationwide secondary data. The quality of the number of hospitalizations due to primary healthcare-sensitive conditions was based on assessment of the National Program for Improvement of Access and Quality of Basic Care (PMAQ-AB). The analysis used a hierarchical explanatory model, with the number of the number of hospitalizations due to primary healthcare-sensitive conditions hospitalizations in the year 2014 as the dependent variable and sociodemographic and health system data as the independent variables. The measure of association between the number of hospitalizations and quality of PHC was calculated with negative binomial regression with robust variance and the total population as offset, with significance set at 20% in the univariate analysis and 5% in the multivariate analysis. The mean number of hospitalizations due to primary healthcare-sensitive conditions admissions during the target period was 359.97 hospitalizations per municipality. The quality of PHC showed a negative association with the number of hospitalizations due to primary healthcare-sensitive conditions admissions. Municipalities with lower quality of PHC (quartile 1) showed 21.2% more number of hospitalizations due to primary healthcare-sensitive conditions admissions than municipalities with higher quality (95%CI: 1.09-1.34). The results showed that quality of PHC in Brazil reduced hospitalizations due to primary healthcare-sensitive conditions, even in contexts of social vulnerability.

Pesquisa científica, atenção primária e medicina de família

Apesar do grande crescimento da nossa especialidade nos últimos 30 anos, ainda estamos muito aquém de atender à demanda brasileira por médicos de família. Atualmente representamos apenas 1,4% do total de médicos especialistas no Brasil e menos de 5% do total de vagas de residência no país são destinados à medicina de família e comunidade (MFC). Com 70% da nossa população coberta pela Estratégia de Saúde da Família, apenas uma parcela pequena conta com um médico de família treinado por um programa de residência em MFC. Infelizmente temos poucas evidências mostrando o impacto do treinamento em MFC no cuidado das pessoas e muito do que sustentamos no nosso discurso como diferenciais da nossa prática carece de provas científicas. Isso perpetua uma noção comum entre formuladores de políticas e gestores de que a atenção primária à saúde (APS) é uma área de atuação desprovida de desafios, sem complexidades e possível de ser realizada por qualquer médico sem treinamento especializado. Se a MFC pretende se firmar como a especialidade médica responsável pela APS no Brasil e no mundo, precisa avançar no desenvolvimento de habilidades para a pesquisa, para poder estudar o universo da MFC e da APS com a profundidade e o rigor que a complexidade destas disciplinas demanda. Desenvolver o potencial para a pesquisa representa um passo importante do projeto profissionalizante da nossa especialidade e do amadurecimento da APS. Ao questionarmos nossa prática e ao perguntarmos o quanto realmente fazemos a diferença no cuidado dos nossos pacientes estaremos ampliando a base de evidências da nossa especialidade e demonstrando o quanto a APS se torna mais abrangente ao ter um médico treinado em MFC. Este ensaio aborda as dificuldades da MFC em mostrar seu valor e a sua importância para os sistemas de saúde; e apresenta o papel vital que a pesquisa científica deve ter no enfrentamento destes desafios.

Role of Interprofessional primary care teams in preventing avoidable hospitalizations and hospital readmissions in Ontario, Canada: a retrospective cohort study

BACKGROUND

Improving health system value and efficiency are considered major policy priorities internationally. Ontario has undergone a primary care reform that included introduction of interprofessional teams. The purpose of this study was to investigate the relationship between receiving care from interprofessional versus non-interprofessional primary care teams and ambulatory care sensitive condition (ACSC) hospitalizations and hospital readmissions.

METHODS

Population-based administrative databases were linked to form data extractions of interest between the years of 2003-2005 and 2015-2017 in Ontario, Canada. The data sources were available through ICES. The study design was a retrospective longitudinal cohort. We used a "difference-in-differences" approach for evaluating changes in ACSC hospitalizations and hospital readmissions before and after the introduction of interprofessional team-based primary care while adjusting for physician group, physician and patient characteristics.

RESULTS

As of March 31st, 2017, there were a total of 778 physician groups, of which 465 were blended capitation Family Health Organization (FHOs); 177 FHOs (22.8%) were also interprofessional teams and 288 (37%) were more conventional group practices ("non-interprofessional teams"). In this period, there were a total of 13,480 primary care physicians in Ontario of whom 4848 (36%) were affiliated with FHOs-2311 (17.1%) practicing in interprofessional teams and 2537 (18.8%) practicing in non-interprofessional teams. During that same period, there were 475,611 and 618,363 multi-morbid patients in interprofessional teams and non-interprofessional teams respectively out of a total of 2,920,990 multi-morbid adult patients in Ontario. There was no difference in change over time in ACSC admissions between interprofessional and non-interprofessional teams between the pre- and post intervention periods. There were no statistically significant changes in all cause hospital readmission s between the post- and pre-intervention periods for interprofessional and non-interprofessional teams.

CONCLUSIONS

Our study findings indicate that the introduction of interprofessional team-based primary care was not associated with changes in ACSC hospitalization or hospital readmissions. The findings point for the need to couple interprofessional team-based care with other enablers of a strong primary care system to improve health services utilization efficiency.

Mortality from oral and oropharyngeal cancer in Brazil: impact of the National Oral Health Policy

The objective was to investigate if there is an association between the mortality rates due to oral and oropharyngeal cancer in Brazil and the expansion of access to public primary and specialized dental care services that resulted from the implementation of the National Oral Health Policy, between 2000 and 2013. The mortality data were obtained from the records of the Mortality Information System and the exposure variables were obtained from databases of the Brazilian Ministry of Health and the Brazilian Institute of Geography and Statistics. The main exposures investigated were "coverage of primary dental care" and "number of specialized dental care centers". Additional covariates included "Gini index of household income", "average number of years of study", "proportion of unemployed people" and "proportion of smokers". For the statistical analysis, a random coefficient model was used. There was a statistically significant association between the mortality rates by oral and oropharyngeal cancer with coverage by primary dental care and the number of specialized dental care centers with males. This study found that the expansion of the coverage of primary dental care and the number of specialized dental care centers are associated with the reduction of mortality rates due to oral and oropharyngeal cancer in Brazil. There is plausibility for the association found, which needs to be confirmed by implementation studies.

Hospitalisations due to ambulatory care sensitive conditions (ACSC) between 2009 and 2018 in Brazil's Federal District as compared with other state capitals

This study compared standardised rates of hospitalisations due to ambulatory care sensitive conditions (ACSCs) in Brazil's Federal District from 2009 to 2018, as compared with those for selected state capitals, age groups and admissions groups. This ecological study used secondary data drawn from Hospital Information System microdata for the study period, during which, in the Federal District, the proportion of such admissions among 50-59 and 60-69 year olds declined, while those among children and adolescents held stable. Meanwhile, rates did not decrease in the ≤ 20 year age groups, a priority population in PHC, which may suggest that this population encountered barriers to access. The results showed that the expected reduction in the proportion of such admissions has not occurred, because coverage by Family Health Teams has been expanded only recently.

Longitudinality in Primary Health Care: a comparison between care models

OBJECTIVE

to evaluate the attribute longitudinality in different models of assistance in Primary Health Care and observe its association with demographic, socioeconomic and health care characteristics.

METHOD

a cross-sectional study, carried out in 2015 with 1076 adult users of primary care services in the 32 cities of the 4th Regional Health Care Core of Rio Grande do Sul State. The Primary Care Assessment Tool was used with definition of low (<6.6) or high (≥6.6) score for longitudinality. The association with independent variables was observed through the Poisson regression.

RESULTS

the attribute was better assessed in the Family Health Strategy and associate with age, housing health region and care model.

CONCLUSION

the study points out the Family Health Strategy as a promoter of longitudinal care, and so, it suggests the expansion of this assistance model coverage for quality improvement in health care.

Social Determinants, Conditions and Performance of Health Services in Latin American Countries, Portugal and Spain

Comparison can be an important resource for identifying trends or interventions that improve the quality of health services. Although Portugal and Spain have accumulated important knowledge in primary health care-PHC driven national systems, the Ibero-American countries have not been object of comparative studies. This paper presents an assessment using an analytical dashboard created by the Ibero-American Observatory on Policies and Health Systems. It discusses aspects that have stood out in monitoring the service systems of Argentina, Brazil, Colombia, Spain, Paraguay, Peru, and Portugal throughout the 21st century's first decade. Forty-five indicators and time series showing the highest completeness degree divided into social determinants, conditions and performance were analyzed. Three trends are common to almost all countries: overweight increase, negative trade balance for pharmaceutical products, and an increase in health system expenditure. This convergence trend reveals the need for changes in the way of regulating, organizing and delivering health services with public policies and practices that guarantee comprehensive care, including health promotion actions enabling systems sustainability.

Acesso ao cuidado na Atenção Primária à Saúde brasileira: situação, problemas e estratégias de superação

RESUMO Sistemas de saúde universais orientados pela Atenção Primária à Saúde (APS) apresentam melhores resultados para a população. Este artigo apresenta a situação do acesso ao cuidado na APS brasileira, seus problemas, desafios e estratégias para sua superação. Realizou-se uma revisão narrativa, incluindo estudos quali e quantitativos. O acesso na APS aumentou com a expansão da Estratégia Saúde da Família (ESF), mas ainda permanece insuficiente. As principais barreiras ao acesso incluem: subdimensionamento/subfinanciamento da APS, excesso de usuários vinculados às equipes da ESF, número reduzido de Médicos de Família e Comunidade (MFC), com pouca interiorização/fixação, burocratização e problemas funcionais dos serviços, como rigidez nos agendamentos e priorização de grupos específicos (hipertensos, puericultura etc.). Para melhorar o acesso, é necessário aumentar o investimento federal na ESF, priorizando-a e expandindo-a, reduzir os usuários vinculados às equipes, ampliar a formação médica em MFC, explorar a clínica da enfermagem, diversificar os meios de comunicação com usuários, explorar a cogestão da equipe e flexibilizar as agendas dos profissionais. Conclui-se que, para fortalecer a APS, é estratégico estimular o acesso na ESF vinculado ao cuidado longitudinal.

Intra-urban differences in rates of admissions for ambulatory care sensitive conditions in Brazil's Center-West region

Admissions for ambulatory care sensitive conditions (ACSCs) represent a useful indicator of assess to and the effectiveness of primary health care. This article examined rates of admissions for ACSCs and the main causes of admissions in intra-urban areas of the municipality of Goiânia, capital of the State of Goiás. An ecological study was conducted to determine rates of admissions in Goiânia's seven health districts between 2008 and 2013 using data from Hospital Admission Authorization forms obtained from the municipality's Hospital Information System. Admissions were georeferenced throughout the seven health districts. Age-adjusted rates of admissions for ACSCs were calculated and the most common causes of admissions were identified for each age group. A 95% confidence interval was calculated as a measure of precision of the rates. The average overall rate of admissions for ACSCs was 155.5 per 10,000 population. Rates were highest in the Southern District and lowest in the Southwest District. Rates were highest in the youngest and oldest age groups. The Northwest District showed the highest rates in nine groups of causes, notably chronic non-communicable diseases among adults. Our findings showed that there are major differences in rates across health districts, pointing to shortfalls in primary health coverage, quality problems and an inadequate care model in districts with high coverage.

[Universal health coverage and the More Doctors physician recruitment program (Programa Mais Médicos) in BrazilCobertura universal de salud y el programa Más Médicos (Programa Máis Médicos) en Brasil]

A cobertura universal pode ser entendida como uma meta que engloba diversas medidas que permitem a ampliação do acesso pelos sistemas de saúde. A atenção primária à saúde (APS) deve ser vista como um aspecto essencial desse processo, com papel de re-organização dos serviços com base nas necessidades em saúde. O Programa Mais Médicos no Brasil traz uma série de medidas para fortalecer a APS no país. A partir de uma revisão conceitual de cobertura universal em saúde e de uma análise do Programa Mais Médicos sob a ótica dos resultados obtidos em termos de fortalecimento da APS no Sistema Único de Saúde (SUS), o objetivo do artigo foi discutir a potencial contribuição do Programa Mais Médicos para o avanço do sistema de saúde brasileiro rumo à cobertura universal. Conclui-se que o Programa Mais Médicos é um propulsor para o alcance da cobertura universal no SUS.

Hospitalization for primary care susceptible conditions, health spending and Family Health Strategy: an analysis of trends

The goal of this study was to analyze the trend over time of hospitalizations due to conditions susceptible to primary healthcare (HCSPC), and how it relates to healthcare spending and Family Health Strategy (FHS) coverage in the city of São Leopoldo, Rio Grande do Sul State, Brazil, between 2003 and 2012. This is an ecological, time-trend study. We used secondary data available in the Unified Healthcare System Hospital Data System, the Primary Care Department and Public Health Budget Data System. The analysis compared HCSPC using three-year moving averages and Poisson regressions or negative binomials. We found no statistical significance in decreasing HCSPC indicators and primary care spending in the period analyzed. Healthcare spending, per-capita spending and FHS coverage increased significantly, but we found no correlation with HCSPC. The results show that, despite increases in the funds invested and population covered by FHS, they are still insufficient to deliver the level of care the population requires.

[Trends in hospitalization for primary care-sensitive conditions and associated factors in Porto Alegre, Rio Grande do Sul, Brazil]

An ecological study was conducted to analyze trends in hospitalization for primary care-sensitive conditions linking the results to the investments in health and coverage of the Family Health Strategy in Porto Alegre, between 1998 and 2012. The causes of hospitalization for primary care-sensitive conditions were based on the national list provided by the Ministry of Health. The data were obtained from the Hospital Information System of the Unified Health System (SUS). Standardized rates were created and investments increased by 27%, though investments in primary care increased by 83%. The expansion of coverage by the Family Health Strategy was almost fourfold, though it remained below the recommended values. There was no change in the trend of hospitalization for primary care-sensitive conditions. The analysis did not make it possible to establish if patients who were hospitalized for primary care-sensitive conditions had access to the Family Health Strategy or not, suggesting the need to incorporate data of place of origin in the information system. Studies using the Hospital Information System contribute to its enhancement, fomenting the assessment, management and design of health policies.

The impact of the Brazilian family health strategy on selected primary care sensitive conditions: A systematic review

Background

Brazil has the largest public health-system in the world, with 120 million people covered by its free primary care services. The Family Health Strategy (FHS) is the main primary care model, but there is no consensus on its impact on health outcomes. We systematically reviewed published evidence regarding the impact of the Brazilian FHS on selective primary care sensitive conditions (PCSC).

Methods

We searched Medline, Web of Science and Lilacs in May 2016 using key words in Portuguese and English, without language restriction. We included studies if intervention was the FHS; comparison was either different levels of FHS coverage or other primary health care service models; outcomes were the selected PCSC; and results were adjusted for relevant sanitary and socioeconomic variables, including the national conditional cash transfer program (Bolsa Familia). Due to differences in methods and outcomes reported, pooling of results was not possible.

Results

Of 1831 records found, 31 met our inclusion criteria. Of these, 25 were ecological studies. Twenty-one employed longitudinal quasi-experimental methods, 27 compared different levels the FHS coverage, whilst four compared the FHS versus other models of primary care. Fourteen studies found an association between higher FHS coverage and lower post-neonatal and child mortality. When the effect of Bolsa Familia was accounted for, the effect of the FHS on child mortality was greater. In 13 studies about hospitalizations due to PCSC, no clear pattern of association was found. In four studies, there was no effect on child and elderly vaccination or low-birth weight. No included studies addressed breast-feeding, dengue, HIV/AIDS and other neglected infectious diseases.

Conclusions

Among these ecological studies with limited quality evidence, increasing coverage by the FHS was consistently associated with improvements in child mortality. Scarce evidence on other health outcomes, hospitalization and synergies with cash transfer was found.

Hospitalizações por condições sensíveis à atenção primária em Pelotas: 1998 a 2012

RESUMO: Objetivo: Verificar a tendência das taxas de internações por condições sensíveis à atenção primária no município de Pelotas, Rio Grande do Sul, de 1998 a 2012. Métodos: Foi realizado estudo ecológico comparando as taxas de Pelotas com as do restante do estado do Rio Grande do Sul. Na análise, fez-se padronização direta das taxas, os coeficientes foram estratificados por sexo e utilizou-se regressão de Poisson. Resultados: As internações por condições sensíveis diminuíram em Pelotas e no Rio Grande do Sul. Em Pelotas a redução das taxas no período foi de 63,8%, e no restante do Rio Grande do Sul, de 43,1%. Os coeficientes da regressão de Poisson mostraram diminuição de 7% no município de Pelotas e de 4% nas outras partes do Rio Grande do Sul por ano. Conclusão: Durante o período estudado, diversas alterações foram introduzidas no Sistema Único de Saúde (SUS), as quais podem ter contribuído para os resultados encontrados, como modificações na modalidade de gestão, nas formas de financiamento em saúde e na reestruturação da atenção primária mediante a consolidação da Estratégia Saúde da Família.

Internações por condições sensíveis à atenção primária em Novo Hamburgo, Rio Grande do Sul

Objetivos: O presente estudo teve por objetivo analisar a tendência das internações por condições sensíveis à atenção primária (ICSAP) em Novo Hamburgo, comparando-a com o restante do Estado do Rio Grande do Sul, e relacionando-a com os investimentos financeiros em saúde e a cobertura da Estratégia Saúde da Família (ESF) no município, no período de 1998 a 2012. Métodos: Foi realizado um estudo ecológico. Os dados foram coletados do Sistema de Internações Hospitalares do SUS. As causas de ICSAP foram baseadas na lista do Ministério da Saúde. A tendência das ICSAP em Novo Hamburgo e no restante do Estado do Rio Grande do Sul foram analisadas por meio dos seus coeficientes padronizados, pelas médias móveis a cada três anos e pela Regressão Binomial Negativa. Foi realizada análise de correlação entre as variáveis de interesse. Resultados: Apesar do aumento de 329,26% nos investimentos financeiros e da expansão da cobertura por ESF no período, atingindo 20,20% da população, não houve diminuição nas tendências dos coeficientes de ICSAP em Novo Hamburgo. No restante do Rio Grande do Sul houve redução nas ICSAP, contudo, os coeficientes foram maiores do que em Novo Hamburgo no período estudado. Conclusões: Embora no presente estudo não tenha sido encontrada associação entre a diminuição nos coeficientes de ICSAP com o aumento da cobertura pela ESF, incremento do investimento financeiro em saúde, investimento financeiro em APS e o gasto per capita em saúde, há evidências que estes estejam correlacionados. Provavelmente, a cobertura de ESF não foi suficiente para impactar as ICSAP.

Hospitalizations due to primary care-sensitive conditions among children under five years of age: cross-sectional study

CONTEXT AND OBJECTIVE:

Hospitalizations due to primary care-sensitive conditions constitute an important indicator for monitoring the quality of primary healthcare. This study aimed to describe hospitalizations due to primary care-sensitive conditions found among children under five years of age (according to their age and sex), in two cities in Paraíba, Brazil.

DESIGN AND SETTING:

Cross-sectional study carried out in the municipalities of Cabedelo and Bayeux, in Paraíba, Brazil.

METHODS:

Data were collected from four public pediatric hospitals in Paraíba that receive children from these municipalities. Hospital admission authorizations were consulted to gather information on the children's profile and the characteristics of their hospitalizations. Differences in the causes of admissions and the respective lengths of hospital stay length were analyzed according to age group and sex.

RESULTS:

The proportion of hospital admissions due to primary care-sensitive conditions was 82.4%. The most frequent causes were: bacterial pneumonia (59.38%), infectious gastroenteritis and its complications (23.59%) and kidney and urinary tract infection (9.67%). Boys had higher frequency of hospitalizations due to primary care-sensitive conditions than girls. The median hospitalization due to primary care-sensitive conditions was found to be four days. The duration of hospital stays due to primary care-sensitive conditions was significantly longer than those due to conditions that were not sensitive to primary care.

CONCLUSIONS:

High rates of hospital admissions due to primary care-sensitive conditions were highlighted, especially among children of male sex, with long periods of hospitalization.

Preceptoria em Medicina de Família e Comunidade: desafios e realizações em uma Atenção Primária à Saúde em construção

Resumo O fortalecimento da Atenção Primária à Saúde (APS) depende diretamente da formação de médicos especialistas em cuidados primários. Este texto tem como objetivo relatar as experiências de formação em Medicina de Família e Comunidade (MFC) no município do Rio de Janeiro entre os anos 2008 e 2016, tendo como objeto de reflexão o desenvolvimento de preceptores no âmbito da especialização médica, por meio do relato de experiência de três programas de Residência Médica em MFC (PRMFC): da Secretaria Municipal de Saúde (SMS), da Universidade Federal do Rio de Janeiro e da Escola Nacional de Saúde Pública. Dentro do cenário de reforma da APS no Rio de Janeiro criou-se a demanda por médicos especialistas para atuação na rede levando à ampliação dos PRM já estabelecidos e à criação do PRMFC-SMS, propiciando novos espaços de ensino em muitas unidades de saúde da rede municipal. Por caminhos distintos esses PRM avançaram na capacitação de seus preceptores, ofertando cursos e ações locais permanentes, na busca por maior qualificação profissional e melhor equilíbrio entre as responsabilidades de cuidado e de ensino. Investimentos permanentes no fortalecimento dos PRM e na capacitação de preceptores são essenciais para consolidar a reforma na APS em todo o Brasil.

Health Equity Indicators for the English NHS: a longitudinal whole-population study at the small-area level

Background

Inequalities in health-care access and outcomes raise concerns about quality of care and justice, and the NHS has a statutory duty to consider reducing them.

Objectives

The objectives were to (1) develop indicators of socioeconomic inequality in health-care access and outcomes at different stages of the patient pathway; (2) develop methods for monitoring local NHS equity performance in tackling socioeconomic health-care inequalities; (3) track the evolution of socioeconomic health-care inequalities in the 2000s; and (4) develop ‘equity dashboards’ for communicating equity findings to decision-makers in a clear and concise format.

Design

Longitudinal whole-population study at the small-area level.

Setting

England from 2001/2 to 2011/12.

Participants

A total of 32,482 small-area neighbourhoods (lower-layer super output areas) of approximately 1500 people.

Main outcome measures

Slope index of inequality gaps between the most and least deprived neighbourhoods in England, adjusted for need or risk, for (1) patients per family doctor, (2) primary care quality, (3) inpatient hospital waiting time, (4) emergency hospitalisation for chronic ambulatory care-sensitive conditions, (5) repeat emergency hospitalisation in the same year, (6) dying in hospital, (7) mortality amenable to health care and (8) overall mortality.

Data sources

Practice-level workforce data from the general practice census (indicator 1), practice-level Quality and Outcomes Framework data (indicator 2), inpatient hospital data from Hospital Episode Statistics (indicators 3–6) and mortality data from the Office for National Statistics (indicators 6–8).

Results

Between 2004/5 and 2011/12, more deprived neighbourhoods gained larger absolute improvements on all indicators except waiting time, repeat hospitalisation and dying in hospital. In 2011/12, there was little measurable inequality in primary care supply and quality, but inequality was associated with 171,119 preventable hospitalisations and 41,123 deaths amenable to health care. In 2011/12, > 20% of Clinical Commissioning Groups performed statistically significantly better or worse than the England equity benchmark.

Limitations

General practitioner supply is a limited measure of primary care access, need in deprived neighbourhoods may be underestimated because of a lack of data on multimorbidity, and the quality and outcomes indicators capture only one aspect of primary care quality. Health-care outcomes are adjusted for age and sex but not for other risk factors that contribute to unequal health-care outcomes and may be outside the control of the NHS, so they overestimate the extent of inequality for which the NHS can reasonably be held responsible.

Conclusions

NHS actions can have a measurable impact on socioeconomic inequality in both health-care access and outcomes. Reducing inequality in health-care outcomes is more challenging than reducing inequality of access to health care. Local health-care equity monitoring against a national benchmark can be performed using any administrative geography comprising ≥ 100,000 people.

Future work

Exploration of quality improvement lessons from local areas performing well and badly on health-care equity, improved methods including better measures of need and risk and measures of health-care inequality over the life-course, and monitoring of other dimensions of equity. These indicators can also be used to evaluate the health-care equity impacts of interventions and make international health-care equity comparisons.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The effects of a people-centred model on longitudinality of care and utilization pattern of healthcare services--Brazilian evidence

Brazil is experiencing a time of change in pattern of care: from ‘traditional’ to Family Health Strategy (FHS), a model guided by the principles of people, family and community-centred medicine. The heterogeneity in care currently offered affects the primary care impact. This study aims to evaluate the longitudinality of care and correlate this primary care principle to the utilization pattern of care among patients hospitalized due to preventable conditions, comparing the two care models currently offered in Brazil. It is a cross-sectional, analytical and descriptive study with a quantitative approach. The sample consisted of 501 patients from 0 to 14 years old. Data was collected in 2011 and the Primary Care Assessment Tool (PCATool-Brazil) child version was used. Bivariate and multivariate analyses were performed including patient-related variables (age, maternal education, income and type of diagnosis) and care model. From the hospitalizations occurred during the period, 65.2% were Ambulatory Care Sensitive Conditions. Patients evaluated ‘longitudinality’ as regular. Both the care continuity dimension and the utilization pattern of care services showed a link with the care model offered. Findings suggest that the FHS care model, based on the assumptions of people-centred medicine, was associated with better ratings of care continuity, which was reflected in a more appropriate utilization pattern of care services.

Socio-demographic caracteristics and prevalence of risk factors in a hypertensive and diabetics population: a cross-sectional study in primary health care in Brazil

BACKGROUND

Systemic arterial hypertension and diabetes mellitus, and their related morbidity and mortality, are currently the most common public health problems and also a higher burden of disease in Brazil. They represent a real challenge for primary health care. This study describes the methodology and baseline data of an adult population with hypertension and diabetes attending in primary health care.

METHODS

It is a cross sectional study which presents data from a longitudinal research. 3784 adults were randomly selected from the registry of a health service in Porto Alegre, Brazil. The eligibility criteria were: confirmed diagnosis of hypertension and/or diabetes, consulted at least once in the prior 3 years and 18 years of age or older. Home data collection consisted of a questionnaire with information on demographic, medical history, life style and socio-economic factors.

RESULTS

A total of 2482 users were interviewed (response rate of 71 %). The median age was 64 (IQR = 55.7) and the majority were women (68 %), and married (52 %). Whereas 66.5 % (CI 95 % 64.5-68.3) of the sample had only hypertension, 6.5 % (CI 95 % 5.5-7.5) had diabetes and 27.1 % (CI 95 % 25.3-28.8) had both diseases. The prevalence of diseases increased with age and with fewer years of study (p < 0.05). Subjects with both diseases had significantly more associated comorbidities.

CONCLUSIONS

Hypertension and diabetes are more prevalent in older individuals, especially women, and less educated people. People suffering with both chronic conditions simultaneously are more likely to have additional comorbidities.

Primary health care quality and hospitalizations for ambulatory care sensitive conditions in the public health system in Porto Alegre, Brazil

PURPOSE

To investigate the relation of hospitalization for ambulatory care sensitive conditions (ACSC) with the quality of public primary care health services in Porto Alegre, Brazil.

METHODS

Cohort study constructed by probabilistic record linkage performed from August 2006 to December 2011 in a population ≥18 years of age that attended public primary care health services. The Primary Care Assessment Tool (PCATool-Brazil) was used for evaluation of primary care services.

RESULTS

Of 1200 subjects followed, 84 were hospitalized for primary care sensitive conditions. The main causes of ACSC hospital admissions were cardiovascular (40.5%) and respiratory (16.2%) diseases. The PCATool average score was 5.3, a level considerably below that considered to represent quality care. After adjustment through Cox proportional hazard modelling for covariates, >60 years of age [hazard ratio (HR): 1.13; P = 0.001), lesser education (HR: 0.66; P = 0.02), ethnicity other than white (HR: 1.77; P = 0.01) and physical inactivity (HR: 1.65; P = 0.04) predicted hospitalization, but higher quality of primary health care did not.

CONCLUSION

Better quality of health care services, in a setting of overwhelmingly low quality services not adapted to the care of chronic conditions, did not influence the rate of avoidable hospitalizations, while social and demographic characteristics, especially non-white ethnicity and lesser schooling, indicate that social inequities play a predominant role in health outcomes.

Identification and characteristics of patients with palliative care needs in Brazilian primary care

Background

The Brazilian healthcare system offers universal coverage but lacks information about how patients with PC needs are serviced by its primary care program, Estratégia Saúde da Família (ESF).

Methods

Cross-sectional study in community settings. Patients in ESF program were screened using a Palliative Care Screening Tool (PCST). Included patients were assessed with Karnofsky Performance Scale (KPS), Edmonton Symptom Assessment System (ESAS) and Palliative Care Outcome Scale (POS).

Results

Patients with PC needs are accessing the ESF program regardless of there being no specific PC support provided. From 238 patients identified, 73 (43 women, 30 men) were identified as having a need for PC, and the mean age was 77.18 (95 % Confidence Interval = ±2,78) years, with non-malignant neurologic conditions, such as dementia and cerebrovascular diseases, being the most common (53 % of all patients). Chronic conditions (2 or more years) were found in 70 % of these patients, with 71 % scoring 50 or less points in the KPS. Overall symptom intensity was low, with the exception of some cases with moderate and high score, and POS average score was 14.16 points (minimum = 4; maximum = 28). Most patients received medication and professional support through the primary care units, but limitations of services were identified, including lack of home visits and limited multi-professional approaches.

Conclusion

Patients with PC needs were identified in ESF program. Basic health care support is provided but there is a lack of attention to some specific needs. PC policies and professional training should be implemented to improve this area.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-016-0125-4) contains supplementary material, which is available to authorized users.

Sickness absence among health workers in belo horizonte, brazil

OBJECTIVES

To describe the prevalence of sickness absence and to analyze factors associated with the outcome according to gender in a sample of healthcare workers at the Belo Horizonte Health Department.

METHOD

This study was based on a Belo Horizonte Health Department survey carried out between September 2008 and January 2009. From a randomly selected sample of 2,205 workers, 1,808 agreed to participate. Workers were classified into Health Staff or Health Care. Other explanatory variables were social and demographic data, work characteristics, and personal health. The Poisson regression was applied to analyze factors associated with sickness absence by the prevalence ratio (PR).

RESULTS

The overall prevalence of sickness absence was 31.5% (23.8% for men and 34.6% for women). In the final model, we found higher rates of sickness absence in both male and female workers involved in tasks with high psychosocial demands (PR=1.86 men; PR=1.38 women) and in those that reported using medication for treating chronic diseases (PR=1.96 men; PR=1.50 women). Women having a permanent job contract had a higher prevalence of sickness absence than those having a temporary job contract (PR=1.71).

CONCLUSION

Our findings suggest a paradox in how healthcare is organized: good results in terms of its global objective of providing healthcare for citizens contrast with lack of effective measures for protecting healthcare workers.

Influência da organização do trabalho sobre a prevalência de transtornos mentais comuns dos agentes comunitários de saúde de Belo Horizonte

Resumo Introdução: à medida que se reconhece o papel dos agentes comunitários de saúde (ACS) para os objetivos do sistema de saúde, é evidente a preocupação com a prevalência de sintomas psíquicos entre esses trabalhadores, conclamando a identificação de indicadores passíveis de serem modificados em favor da saúde mental dos ACS. Objetivo: examinar associações entre a prevalência de transtornos mentais comuns (TMC) e condições de trabalho entre ACS inseridos nos serviços de atenção básica de Belo Horizonte, MG. Método: a amostra aleatória e representativa incluiu 196 sujeitos. Utilizou-se o Self-Reporting Questionnaire (SRQ-20) e questionário autopreenchível que continha blocos relacionados às questões sociodemográficas, ocupacionais e hábitos de vida. A análise multivariável adotou entrada hierárquica das variáveis e regressão de Poisson com estimativa da variância robusta. Resultados: a prevalência de TMC de 26,5% foi associada à alta demanda psicológica, relato de agressões contra o trabalhador e insatisfação com as relações pessoais. Conclusão: a significância da associação no tocante à demanda psicológica no trabalho é preocupante, pois seria possível projetar o trabalho dos ACS sem ultrapassar os seus próprios limites. Adequações do modelo organizacional e redesenho das tarefas podem contribuir favoravelmente para a saúde mental dos ACS.

Influência de fatores estruturais e organizacionais no desempenho da atenção primária à saúde em Belo Horizonte, Minas Gerais, Brasil, na avaliação de gestores e enfermeiros

O objetivo do trabalho foi avaliar o desempenho da atenção primária à saúde (APS) em Belo Horizonte, Minas Gerais, Brasil, utilizando o questionário PCATool entre enfermeiros das equipes de saúde da família e gerentes. O escore total da APS foi 0,75 (bom); o primeiro contato (0,95), a longitudinalidade (0,83), a integralidade (0,83) e a coordenação (0,78) apresentaram melhor desempenho. O enfoque familiar, a orientação comunitária e o acesso receberam as piores pontuações (0,68, 0,56 e 0,45). Os fatores associados (p < 0,05) à melhor performance da APS foram: disponibilidade de equipamentos e outros insumos (RP ajustada = 1,57), formação dos profissionais em saúde da família (RP = 1,44), presença do médico por mais de 30 horas semanais (RP = 1,42) e quatro ou mais equipes por unidade básica de saúde (RP = 1,09). Os resultados revelaram a importância de fatores estruturais (sistemas logísticos adequados, formação da equipe em saúde da família) e organizacionais (médico em tempo integral, número de equipes da Estratégia Saúde da Família por unidades básicas de saúde) na performance da APS e na melhoria da qualidade.

Análise da tendência das taxas de internações por pneumonia bacteriana em crianças e adolescentes

Objetivo Analisar a distribuição e a tendência das taxas de internações por pneumonia bacteriana em crianças e adolescentes. Métodos Estudo ecológico de séries temporais com dados secundários obtidos no Sistema de Informações Hospitalares do Sistema Único de Saúde. Foram calculados coeficientes de internação para 10.000 habitantes, por triênio. Para análise de tendência utilizaram-se modelos de regressão polinomial. Resultados As maiores taxas de internação ocorreram na Macrorregião de Saúde Oeste, entre o segundo e o quarto triênio. As taxas foram maiores na faixa etária de um a quatro anos e no sexo masculino, durante todo o período. Observou-se tendência crescente das internações em crianças menores de um ano. Conclusão As taxas de internação por pneumonia diferem por macrorregional de saúde, idade e sexo, sendo maior na região oeste, em crianças do sexo masculino e com idade entre um e quatro anos, com tendência crescente entre os menores de um ano.

A equidade na cobertura da Estratégia Saúde da Família em Minas Gerais, Brasil

A Estratégia Saúde da Família (ESF) tem papel relevante na prevenção e no acompanhamento das famílias no Sistema Único de Saúde. O presente estudo tem como objetivo analisar a equidade na cobertura desses serviços ofertados na área urbana de Minas Gerais, Brasil. A pesquisa analisa diversos marcadores considerando quatro grupos-alvo: mulheres, gestantes, crianças e idosos, sendo representativa por macrorregião de saúde. Foram investigados em 2012, 6.797 domicílios, sendo entrevistados 5.820 mulheres, 1.758 crianças e 3.629 idosos. Para analisar a equidade, foram construídas taxas de cobertura da ESF por classe de riqueza e estimados índices e curvas de concentração. Os resultados revelam que a ESF é uma política equitativa. Os indicadores mostram que os domicílios mais pobres apresentam maiores taxas de visitação da ESF. Considerando a população residente nas áreas adscritas às equipes de saúde, o nível de cobertura é bastante elevado: 88% da população investigada receberam pelo menos uma visita dos profissionais da ESF nos últimos 12 meses, o que resulta em índices de concentração perto de zero.

[Hierarchical modeling of determinants associated with hospitalizations for ambulatory care sensitive conditions in Espírito Santo State, Brazil]

The aim of this study was to investigate the relationship between health services organization and hospitalization rates for ambulatory care sensitive conditions after adjusting for socioeconomic and demographic variables in municipalities (counties) in Espírito Santo State, Brazil. In an ecological study, data were collected from the Brazilian Unified National Health System (SUS) on the following variables: hospitalization for ambulatory care sensitive conditions, city size, demographic and socioeconomic characteristics, and health services organization. Rates were analyzed by Poisson regression with robust variance. Models were adjusted for the total population and age group. The explanatory variables were ordered hierarchically. Hospitalization rates for ambulatory care sensitive conditions were associated with illiteracy rate (RR: 1.08-1.17), proportion of beds in the SUS (RR: 1.09-1.12), urbanization (RR: 1.02-1.03), proportion of blacks (RR: 0.97-0.98), and health insurance coverage (RR: 0.97-0.98). Some determinants of hospitalization for ambulatory care sensitive conditions involve patterns of health services use and lie outside the scope of primary care.

Redesigning primary care to tackle the global epidemic of noncommunicable disease

Noncommunicable diseases (NCDs) have become the major contributors to death and disability worldwide. Nearly 80% of the deaths in 2010 occurred in low- and middle-income countries, which have experienced rapid population aging, urbanization, rise in smoking, and changes in diet and activity. Yet the health systems of low- and middle-income countries, historically oriented to infectious disease and often severely underfunded, are poorly prepared for the challenge of caring for people with cardiovascular disease, diabetes, cancer, and chronic respiratory disease. We have discussed how primary care can be redesigned to tackle the challenge of NCDs in resource-constrained countries. We suggest that four changes will be required: integration of services, innovative service delivery, a focus on patients and communities, and adoption of new technologies for communication.

Twenty-four-year demographic trends of a Brazilian long-term care institution for the aged

OBJECTIVES

The objectives of this study were to assess demographic trends of a long-term care institution (LTCI) for the aged throughout 24 years and to discuss the results considering regulations and demographic, socioeconomic, and epidemiological changes in Brazil during this period.

METHODS

We assessed administrative data of 394 residents of a Brazilian LTCI between January 1, 1990, and December 31, 2013. We calculated age at admission, age at death, length of stay (LOS), and median age of the residents on December 31 for each year from 1990 to 2013. Annual mortality index and total number of admissions and discharges also were analyzed. We used the Jonckheere-Terpstra trend test and 1-way ANOVA for statistical analysis.

RESULTS

We observed a significant statistical increased trend of the mean age at admission, of the median age of the residents, and of the median LOS throughout the period. There was no increased or decreased trend of the median age at death.

CONCLUSIONS

The increased trend of the mean age at admission and the median age of the residents may reflect improvements in health, socioeconomic status, life expectancy, and the development of protective regulations for older adults in Brazil. The increased trend of the median LOS may reflect the aforementioned improvements, but we expect a future inversion of this trend due to the admission of older, sicker, and more functionally dependent elderly individuals.

[A comparison of the Family Health Strategy to other sources of healthcare: utilization and quality of health services in Belo Horizonte, Minas Gerais State, Brazil]

Indicators of healthcare utilization and quality were compared in a probabilistic sample of adults (N = 7,534) covered by private health plans, the Family Health Strategy (FHS), and "traditional" primary care clinics (UBS) in Belo Horizonte, Minas Gerais State, Brazil. After adjusting for demographics, health conditions, and socioeconomic status, indicators of healthcare utilization (longitudinality, health-seeking, and medical consultations) showed better performance among users of the FHS and private health plans compared to those covered by the UBS. Hospitalizations, preventive tests, and flu vaccinations varied little between sources of care. Quality indicators (difficulty in making an appointment, waiting lines, complaints about obtaining medications, and receiving an appointment within 24 hours) were better among private health plans. Recommending one's healthcare providers to others was more frequent among FHS users (61.9%) and those with private health plans (55.6%), compared to those served by UBS (45.4%).

Internações por Condições Sensíveis à Atenção Primária em uma metrópole brasileira

Este estudo tem como objetivo descrever o perfil das Internações por Condições Sensíveis à Atenção Primária (ICSAP) no município de Curitiba no período de 2005 a 2007. Foi realizado um estudo ecológico, com dados obtidos no Sistema de Informações Hospitalares. Para análise, foi utilizada a estatística descritiva. Observou-se que em Curitiba as ICSAP seguem tendência de estabilização, sendo as causas mais frequentes a angina e a insuficiência cardíaca, maior frequência para o sexo feminino e a faixa etária ≥ 65 anos. Os resultados observados assemelham-se aos de outros estudos e foram, quase na totalidade, altamente significativos do ponto de vista estatístico. Entretanto, devem ser vistos com cuidado, pois se se trata de um indicador que apresenta algumas limitações, dentre as quais a própria confiabilidade do diagnóstico e o uso de dados secundários.

Doenças crônicas não transmissíveis no Brasil: prioridade para enfrentamento e investigação

As Doenças Crônicas Não Transmissíveis representam a maior carga de morbimortalidade no Brasil. Em 2011, o Ministério da Saúde lançou seu Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis, enfatizando ações populacionais para controlar as doenças cardiovasculares, diabetes, câncer e doença respiratória crônica, predominantemente pelo controle do fumo, inatividade física, alimentação inadequada e uso prejudicial de álcool. Apesar da produção científica significativa sobre essas doenças e seus fatores de risco no Brasil, poucos são os estudos de coorte nessa temática. Nesse contexto, o Estudo Longitudinal da Saúde do Adulto (ELSA-Brasil) acompanha 15.105 servidores públicos do País. Seus dados espelham a realidade brasileira de altas prevalências de diabetes e hipertensão e dos fatores de risco. A diversidade das informações produzidas permitirá aprofundar o entendimento causal dessas doenças e subsidiar políticas públicas para seu enfrentamento.

Desempenho de indicadores nos municípios com alta cobertura da Estratégia Saúde da Família no Estado de São Paulo

Introdução: A avaliação do desempenho da Estratégia Saúde da Família tem se mostrado difícil no Estado de São Paulo por razões diversas, como a baixa cobertura da população, associada paradoxalmente a indicadores de saúde acima da média nacional. Objetivo: Avaliar o desempenho de alguns indicadores do “Pacto pela Atenção Básica” e do “Pacto pela Saúde” em municípios do Estado de São Paulo com alta cobertura da Estratégia Saúde da Família em comparação ao restante do Estado. Métodos: Indicadores do “Pacto pela Atenção Básica” e do “Pacto pela Saúde” foram acompanhados nos 110 municípios que alcançaram 90% ou mais de cobertura da Estratégia Saúde da Família em um período mínimo de sete anos e comparados com os indicadores do restante do Estado. Resultados: A taxa de mortalidade infantil apresentou uma tendência de queda muito mais importante em relação ao Estado. A taxa de internação por acidente vascular cerebral mostrou-se maior nos municípios em relação ao Estado. A razão de exames citopatológicos dos municípios da amostra foi quase o dobro da encontrada no Estado; a taxa de alta dos pacientes com tuberculose foi superior em pouco mais de 13% em comparação à média do Estado e a taxa de cura de hansênicos apresentou variação menor (5%), mas favorável à amostra. Conclusões: Os achados sugerem que a estratégia esteja contribuindo para a melhora dos indicadores de processo, bem como de alguns indicadores de resultado, demandando maior seguimento dos últimos. 

Clinical care and health disparities

Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, demographically, or geographically. This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.

The impact of primary care: a focused review

Primary care serves as the cornerstone in a strong healthcare system. However, it has long been overlooked in the United States (USA), and an imbalance between specialty and primary care exists. The objective of this focused review paper is to identify research evidence on the value of primary care both in the USA and internationally, focusing on the importance of effective primary care services in delivering quality healthcare, improving health outcomes, and reducing disparities. Literature searches were performed in PubMed as well as "snowballing" based on the bibliographies of the retrieved articles. The areas reviewed included primary care definitions, primary care measurement, primary care practice, primary care and health, primary care and quality, primary care and cost, primary care and equity, primary care and health centers, and primary care and healthcare reform. In both developed and developing countries, primary care has been demonstrated to be associated with enhanced access to healthcare services, better health outcomes, and a decrease in hospitalization and use of emergency department visits. Primary care can also help counteract the negative impact of poor economic conditions on health.