Entraves no acesso à atenção médica: vivências de pessoas com infarto agudo do miocárdio

Reperfusion Therapy Optimization in Acute Myocardial Infarction with ST-Segment Elevation using WhatsApp®-Based Telemedicine

BACKGROUND

About 40% of patients with ST-segment elevation myocardial infarction (STEMI) in Brazil do not receive reperfusion therapy.

OBJECTIVE

The use of a telemedicine network based on WhatsApp® could increase the percentage of patients receiving reperfusion therapy.

METHODS

A cross-sectional study analyzed outcomes before and after the organization of a telemedicine network to send the electrocardiogram via WhatsApp® of patients suspected of STEMI from 25 municipalities that are members of the Regional Health Department of Ribeirão Preto (DRS-XIII) to a tertiary hospital, which could authorize immediate patient transfer using the same system. The analyzed outcomes included the percentage of patients who received reperfusion therapy and the in-hospital mortality rate. A p value < 0.05 was considered statistically significant.

RESULTS

The study compared 82 patients before (February 1, 2016 to January 31, 2018) with 196 patients after this network implementation (February 1, 2018 to January 31, 2020). After implementing this network, there was a significant increase in the proportion of patients who received reperfusion therapy (60% vs. 92%), relative risk (RR): 1.594 [95% confidence interval (CI) 1.331 - 1.909], p < 0.0001 and decrease in the in-hospital mortality rate (13.4% vs. 5.6%), RR: 0.418 [95%CI 0.189 - 0.927], p = 0.028.

CONCLUSION

The use of WhatsApp®-based telemedicine has led to an increase in the percentage of patients with STEMI who received reperfusion therapy and a decrease in the in-hospital mortality rate.

Clinical Competence in ST-segment Elevation Myocardial Infarction Management by Recently Graduated Physicians Applying for a Medical Residency Program

BACKGROUND

A significant reduction in the morbidity and mortality related to ST-segment elevation myocardial infarction (STEMI) has been achieved with the development of reperfusion therapies. Early diagnosis and correct initial management are important to ensure this benefit. In Brazil, recent graduates in medicine are responsible for a large part of the initial care provided for these patients.

OBJECTIVE

To assess the clinical competence in the diagnosis and initial treatment of STEMI by newly graduated physicians applying for a medical residency program.

METHODS

We assessed the performance of 771 applicants for the direct entry selection process of the FMRP-USP Clinical Hospital Medicine Residency Program, performed in a simulated setting of STEMI, with professional actors and medical evaluators, using a standardized checklist following the recommendations of the Brazilian Guidelines for the management of this disease.

RESULTS

The general performance score presented a median of 7 and an interquartile range of 5.5-8.0. In relation to the items assessed: 83% required ECG monitoring, 57% requested the insertion of a peripheral venous access catheter, 95% administered acetylsalicylic acid, 80% administered a second antiplatelet agent (p2y12 inhibitor), 66% administered nitrate, 71% administered morphine, 69% recognized the diagnosis of STEMI, 71% assessed the pain duration, 63% recognized the need for immediate transfer, 34% showed adequate communication skills and only 25% insisted on the transfer even in case of non-availability of beds.

CONCLUSIONS

The initial diagnosis and management of STEMI need to be improved in medical undergraduate courses and inserted into the reality of the hierarchical network structure of the Brazilian Unified Health System (SUS).

Primary health care and the coordination of care in health regions: managers' and users' perspective

This paper aims to analyze the healthcare coordination by Primary Health Care (PHC), with the backdrop of building a Health Care Network (RAS) in a region in the state of São Paulo, Brazil. We conducted a case study with qualitative and quantitative approaches, proceeding to the triangulation of data between the perception of managers and experience of users. We drew analysis realms and variables from the three pillars of healthcare coordination - informational, clinical and administrative/organizational. Stroke was the tracer event chosen and therapeutic itineraries were conducted with users and questionnaires applied to the managers. The central feature of the construction of the Health Care Network in the studied area is the prominence of a philanthropic organization. The results suggest fragility of PHC in healthcare coordination in all analyzed realms. Furthermore, we identified a public-private mix, in addition to services contracted from the Unified Health System (SUS), with out-of-pocket payments for specialist consultation, tests and rehabilitation. Much in the same way that there is no RAS without a robust PHC capable of coordinating care, PHC is unable to play its role without a solid regional arrangement and a virtuous articulation between the three federative levels.

[Towards a philosophy of medication]

Medicine and philosophy: where do these concepts intersect? From a biopolitical standpoint, the scope of this essay is to highlight the existence of new challenges for those who deal with the issue of pharmaceuticalization in contemporary society. The analyses revealed that essentially technical approaches are insufficient to confront issues such as: the exorbitant profits from the sale of medication; the disproportionate ratio of these amounts with the number of new innovative molecules; and the difficulty of access to the few new drugs. It would seem to be the opportune moment for adopting a more critical stance for drafting a philosophy of medication in the field of public health with the establishment of areas of resistance to the omnipresent pharmacotherapeutic onslaught. After all, medication is not a constitutive element that is isolated from human life; although, it has become a central component in the management of contemporary life, its adequate use requires the exercise of in-depth introspection.

Pre-hospital delay in acute myocardial infarction: judgement of symptoms and resistance to pain

OBJECTIVE

To estimate the time of decision (TD) to look for medical care and the time of arrival (TA) at the health service for men (M) and women (W) suffering from acute myocardial infarction and to analyze the influence of the interpretation of pain and pain resistance behaviors during these times.

METHODS

This is an exploratory research, performed at the university hospital in Salvador/Bahia. 43 W and 54 M were interviewed. To study the dependence among sociodemographic and gender variables, the Fisher Exact Test was used. To analyze times, a geometric mean (GM) was used. In order to verify the association between the GM of TD and TA and the judgment of pain, and between the GM of TD and TA and the behavior of resistance to pain, as well as to test the time of interaction between the gender variable and other variables of interest, the robust regression model was used. The statistical significance adopted was 5%.

RESULTS

The GM of the TD for M was 1.13 h; for W, 0.74 h. The GM of the TA was 1.74 h for M and 1.47 h for W. Those who did not recognize the symptoms of AMI and presented behavior of resistance to pain had higher TD and TA, being the associations significant. Gender did not change the associations of interest.

CONCLUSION

The findings demonstrate the importance of health education aiming at the benefits of early treatment.

Itinerários terapêuticos: o estado da arte da produção científica no Brasil

O conhecimento sobre os itinerários de pessoas em busca de atenção à saúde pode contribuir para compreensão sobre o comportamento em relação ao cuidado e utilização de serviços de saúde. Apesar de sua potencialidade, os estudos sobre itinerários terapêuticos não tem expressão conhecida no Brasil. Este artigo busca apresentar um levantamento da produção científica nacional sobre o assunto nos últimos 20 anos, descrevendo e analisando as abordagens realizadas. Os dados foram coletados durante os meses de setembro e novembro de 2008 através do portal da Biblioteca Virtual em Saúde. A busca resultou em 11 artigos que foram submetidos à análise de conteúdo por meio de categorização. Observou-se que os estudos sobre itinerários terapêuticos no Brasil são recentes e pouco explorados por pesquisadores e gestores. A abordagem socioantropológica oferece suporte teórico à maioria dos estudos realizados. O principal foco de interesse é a percepção do paciente sobre a doença e tratamento. Poucos são os estudos que nessa discussão associam aspectos sobre o acesso e utilização dos serviços e fatores relacionados ao contexto do paciente. Conclui-se que o estudo sobre itinerários terapêuticos pode ser uma importante ferramenta para a qualificação da assistência.