Reforma na atenção primária à saúde e implicações na cultura organizacional dos Agrupamentos dos Centros de Saúde em Portugal

How to develop a sustainable telemedicine service? A Pediatric Telecardiology Service 20 years on - an exploratory study

Background

Telemedicine services are promoting more access to healthcare. Portugal was an early adopter of telemedicine to overcome both its geological barriers and the shortage of healthcare professionals. The Pediatric Cardiology Service (PCS) at Coimbra University Hospital Centre (CHUC) has been using telemedicine to increase access and coverage since 1998. Their Pediatric Telecardiology Service has been daily connecting CHUC with 13 other Portuguese national hospitals, and regularly connecting with Portuguese-speaking African countries, through a teleconsultation platform.

Methods

This study aims at exploring the Pediatric Telecardiology Service’s evolution, through a comprehensive assessment of the PCS’s development, evolution and impact in public health, to better understand the critical factors for implementation and sustainability of telemedicine, in the context of healthcare services digitalization. A case study was performed, with cost-benefit, critical factors and organizational culture assessment. Finally, the Kingdon’s framework helped to understand the implementation and scale-up process and the role of policy-making.

Results

With the total of 32,685 out-patient teleconsultations, growing steadily from 1998 to 2016, the Pediatric Telecardiology Service has reached national and international recognition, being a pioneer and an active promotor of telemedicine. This telemedicine service has saved significant resources, about 1.1 million euros for the health system (e.g. in administrative and logistic costs) and approximately 419 euros per patient (considering an average of 1777 patients per year).

PCS presents a dominant “Clan” culture. The Momentum’s critical factors for telemedicine service implementation enabled us to understand how barriers were overcome (e.g. political forces). Willingness, perseverance and teamwork, allied with partnership with key stakeholders, were the foundation for professionals’ engagement and service networking development. Its positive results, new regulations and the increasing support from the hospital board, set up a window of opportunity to establish a sustainable telemedicine service.

Conclusion

The Pediatric Telecardiology Service enables real-time communication and the sharing of clinical information, overcoming many barriers (from geographical ones to shortage of healthcare professionals), improving access to specialized care both in Portugal and Africa.

Motivation and teamwork, and perseverance, were key for the Pediatric Telecardiology Service to tackle the window of opportunity which created conditions for sustainability.

Emergency department visits for ambulatory care sensitive conditions

OBJECTIVE

To describe emergency department visits for ambulatory care sensitive conditions.

METHOD

Exploratory, descriptive, ecological, quantitative study. From January 2015 to December 2016, was accessed the database with information of visits performed in an emergency department located in the region of Campo Limpo, municipality of São Paulo. A 99% confidence interval was considered for the incidence of visits with identification of ambulatory care sensitive conditions, and a margin of error of 0.4%. The analyzes were performed with use of the statistical package SPSS.

RESULTS

We found 434,883 visits, of which 17.1% were due to ambulatory care sensitive conditions, mostly of women and children up to 4 years of age. The reason for most visits were ear, nose and throat infections (45.4%). There was a higher chance of visits for the indicator in chronic patients (p<0.001).

CONCLUSION

This study demonstrated the emergency department ambulatory care sensitive conditions visits that may indicate poor access to primary care.

Cultura organizacional na área da saúde: um estudo bibliométrico

RESUMO O artigo objetivou identificar as características das pesquisas na área de saúde sobre o tema cultura organizacional publicadas em revistas brasileiras. A busca foi efetuada na Biblioteca Virtual em Saúde a partir do termo ‘cultura organizacional’, no período de 2007 a 2016. Foram encontrados 30 artigos em revistas nacionais de Qualis A1, A2, B1 nas áreas de avaliação Capes (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior): enfermagem, saúde coletiva e psicologia. Os resultados evidenciaram o predomínio de artigos quantitativos e a aplicação de grande variedade de instrumentos para analisar a cultura organizacional na saúde, o que amplia as possibilidades de investigação e análise de diferentes aspectos do tema.

Challenges and strategies to improve the availability and geographic accessibility of physicians in Portugal

BACKGROUND

Shortages of physicians in remote, rural and other underserved areas and lack of general practitioners limit access to health services. The aims of this article are to identify the challenges faced by policy and decision-makers in Portugal to guarantee the availability and geographic accessibility to physicians in the National Health Service and to describe and analyse their causes, the strategies to tackle them and their results. We also raise the issue of whether research evidence was used or not in the process of policy development.

METHODS

We analysed policy and technical documents, peer-reviewed papers and newspaper articles from 1995 to 2015 through a structured search of government websites, Portuguese online newspapers and PubMed and Virtual Health Library (Biblioteca Virtual em Saúde (BVS)) databases; key informants were consulted to validate and complement the documentary search.

RESULTS

The challenges faced by decision-makers to ensure access to physicians were identified as a forecasted shortage of physicians, geographical imbalances and maldistribution of physicians by level of care. To date, no human resources for health policy has been formulated, in spite of most documents reviewed stating that it is needed. On the other hand, various isolated and ad hoc strategies have been adopted, such as incentives to choose family health as a specialty or to work in an underserved region and recruitment of foreign physicians through bilateral agreements.

CONCLUSIONS

Health workforce research in Portugal is scarce, and therefore, policy decisions regarding the availability and accessibility of physicians are not based on evidence. The policy interventions described in this paper should be evaluated, which would be a good starting point to inform health workforce policy development.