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Florêncio RB, de Araújo Fonseca LG, da Silva VFD, Lima ÍNDF, Gualdi LP. Diabetes mellitus hospitalization and mortality rate according to a national database in Brazil: a longitudinal study. BMC Public Health 2021; 21:403. [PMID: 33632201 PMCID: PMC7908752 DOI: 10.1186/s12889-021-10438-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/11/2021] [Indexed: 11/11/2022] Open
Abstract
Background Diabetes mellitus (DM) is an important public health problem worldwide. In addition to the impairment in functionality, the large number of complications which lead to hospitalizations results in high treatment costs. The aim of this study was to analyze the incidence of hospitalizations, mortality rate and hospital costs, as well as to observe the temporal trend of hospitalizations and length of hospital stay due to DM between 2008 and 2019 in Brazil. Methods This is a longitudinal descriptive study in which all data regarding hospital admissions registered in the Brazilian system of Hospital Information of “Sistema Único de Saúde” (SIH/SUS; http://datasus.saude.gov.br) due to DM (ICD-10) were included. Comparisons among the groups were performed by an unpaired Student’s t-test, two-way ANOVA with a Tukey post hoc test (p < 0.05). Results An increased hospitalization of 1.83% due to DM was observed between 2008 and 2019 in Brazil. The Southeastern region had the highest incidence (34.6%) and mortality rate when compared to the other regions (p < 0.05). We also found that females were more likely to be hospitalized in comparison to males, without a statistically significant difference. Finally, a progressive increase of hospitalizations and mortality rate were observed according to age groups, as well as increased spending due to DM hospitalizations over the years. Conclusion Hospitalizations due to DM in Brazil showed an expressive increase over the last 12 years, and there is a need for primary healthcare interventions to help reduce this situation.
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Affiliation(s)
- Rêncio Bento Florêncio
- Mestrando do Programa de Ciências da Reabilitação da Faculdade de Ciências da Saúde do Trairí/Universidade Federal do Rio Grande do Norte - FACISA/UFRN, Santa Cruz, RN, Brazil
| | - Luiza Gabriela de Araújo Fonseca
- Mestrando do Programa de Ciências da Reabilitação da Faculdade de Ciências da Saúde do Trairí/Universidade Federal do Rio Grande do Norte - FACISA/UFRN, Santa Cruz, RN, Brazil
| | - Vivian Fernanda Dantas da Silva
- Graduanda do Curso de Fisioterapia da Faculdade de Ciências da Saúde do Trairí/Universidade Federal do Rio Grande do Norte - FACISA/UFRN, Santa Cruz, RN, Brazil
| | | | - Lucien Peroni Gualdi
- Docente da Faculdade de Ciências da Saúde do Trairí/Universidade Federal do Rio Grande do Norte - FACISA/UFRN, Santa Cruz, RN, Brazil.
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Alves FLMT, Laporta GZ. Prevalence and factors associated with lower limb amputation in individuals with type II diabetes mellitus in a referral hospital in Fortaleza, Ceará, Brazil: A hospital-based cross-sectional study. Heliyon 2020; 6:e04469. [PMID: 32715137 PMCID: PMC7372145 DOI: 10.1016/j.heliyon.2020.e04469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 07/07/2020] [Accepted: 07/13/2020] [Indexed: 12/03/2022] Open
Abstract
AIMS To analyze the association between demographic, socioeconomic, clinical, epidemiological, and primary healthcare factors with the severity of lower limb amputations (LLAs) in individuals with type II diabetes mellitus (DM-II) at a reference hospital in Fortaleza, Ceará, in Northeast Brazil. METHODS A cross-sectional study was performed with a representative sample of individuals hospitalized with DM-II and the degree of LLA severity: (1) toes; (2) transmetatarsal or infrapatellar; (3) suprapatellar; (4) disarticulation or bilateral. Potentially associated factors with the outcome degree of amputation severity were identified in a semi-structured evaluation during hospitalization. The prevalence ratios of the degree of amputation severity as a function of associated factors were calculated with robust variance Poisson regression models. RESULTS The prevalence of high degree of severity in amputations (suprapatellar, with disarticulation or bilateral) was high in the total sample of 385 patients, revealing to be 49% (187/385). Prevalence ratios (PR) indicated a higher prevalence of DM-II amputation severity in patients who lacked of specific guidance on DM-II amputation in primary care (PR = 1.52, 95% CI: 1.05-2.21). CONCLUSIONS LLAs in DM-II were associated with age above 67 years, male gender, cardiovascular disease, and low support for guidance at the primary healthcare level.
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Affiliation(s)
- Francisca Lesse Mary Teixeira Alves
- Setor de Pós-graduação, Pesquisa e Inovação, Centro Universitário Saúde ABC (FMABC), Fundação ABC, Santo André, São Paulo, Brazil
- Hospital Geral de Fortaleza (HGF), Secretaria de Estado da Saúde State, Fortaleza, Ceará, Brazil
| | - Gabriel Zorello Laporta
- Setor de Pós-graduação, Pesquisa e Inovação, Centro Universitário Saúde ABC (FMABC), Fundação ABC, Santo André, São Paulo, Brazil
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Abstract
BACKGROUND The diabetes epidemic affects most countries across the world and is increasing at alarming rates in Latin America. Nearly 12 million individuals have diabetes in Brazil, and the current prevalence ranges from 6.3% to 13.5%, depending on the region and the diagnostic criteria adopted in each study. OBJECTIVE To provide an overview of diabetes care in Brazil, focusing on studies of diabetes epidemiology, prevalence of patients within the standard targets of care, and economic burden of diabetes and its complications. METHODS SciELO and PubMed searches were performed for the terms "diabetes," "Brazil," "Brazilian," and "health system"; relevant literature from 1990 to 2015 was selected. Additional articles identified from reference list searches were also included. All articles selected were published in Portuguese and/or English. FINDINGS Recent studies detected a prevalence of gestational diabetes mellitus of nearly 20%. Among patients with type 1 diabetes, almost 90% fail to reach target of glycemic control, with less than 30% receiving treatment for both hypertension and dyslipidemia. More than 75% of patients with type 2 diabetes are either overweight or obese. Most of these patients fail to reach glycemic targets (42.1%) and less than 30% reached the target for systolic and diastolic blood pressure, body mass index, or low-density lipoprotein cholesterol. Only 0.2% of patients reach all these anthropometric and metabolic targets. CONCLUSIONS Brazil is the fourth country in the world in number of patients with diabetes. Regardless of the diabetes type, the majority of patients do not meet other metabolic control goals. The economic burden of diabetes and its complications in Brazil is extremely high, and more effective approaches for preventions and management are urgently needed.
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Affiliation(s)
- Walmir F Coutinho
- State Institute of Diabetes and Endocrinology (IEDE), Catholic University of Rio de Janeiro, 22451-900, Rio de Janeiro, Brazil.
| | - Wellington Santana Silva Júnior
- Diabetes Department, State Institute of Diabetes and Endocrinology (IEDE), 21330-683, Rio de Janeiro, Brazil; and PhD student in the Postgraduate Program in Clinical and Experimental Physiopathology (FISCLINEX), State University of Rio de Janeiro, 20551-030, Rio de Janeiro, Brazil
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Costa AF, Flor LS, Campos MR, Oliveira AFD, Costa MDFDS, Silva RSD, Lobato LCDP, Schramm JMDA. Burden of type 2 diabetes mellitus in Brazil. CAD SAUDE PUBLICA 2017; 33:e00197915. [PMID: 28380131 DOI: 10.1590/0102-311x00197915] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 05/02/2016] [Indexed: 01/18/2023] Open
Abstract
Type 2 diabetes mellitus currently ranks high among indicators used in Global Burden of Disease Studies. The current study estimated the burden of disease attributable to type 2 diabetes mellitus and its chronic complications in Brazil, 2008. We calculated disability-adjusted life years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs) stratified by gender, age bracket, and major geographic region. Type 2 diabetes mellitus accounted for 5% of the burden of disease in Brazil, ranking 3rd in women and 6th in men in the composition of DALYs. The largest share of DALYs was concentrated in the 30-59-year age bracket and consisted mainly of YLDs. The highest YLL and YLD rates were in the Northeast and South of Brazil, respectively. Chronic complications represented 80% of YLDs from type 2 diabetes mellitus. Type 2 diabetes mellitus ranked as a leading health problem in Brazil in 2008, accounting for relevant shares of mortality and morbidity.
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Affiliation(s)
- Amine Farias Costa
- Instituto Nacional de Câncer José Alencar Gomes da Silva, Rio de Janeiro, Brasil
| | - Luísa Sorio Flor
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Mônica Rodrigues Campos
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | - Maria de Fátima Dos Santos Costa
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Raulino Sabino da Silva
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
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Spatial analysis of hospitalization rate for diabetes mellitus and its complications in the Brazilian population, 2007–2011. Int J Diabetes Dev Ctries 2015. [DOI: 10.1007/s13410-015-0421-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Santos ICRV, Sobreira CMM, Nunes ENDS, Morais MCDA. [The prevalence and factors associated with diabetic foot amputations]. CIENCIA & SAUDE COLETIVA 2014; 18:3007-14. [PMID: 24061027 DOI: 10.1590/s1413-81232013001000025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 05/27/2012] [Indexed: 11/21/2022] Open
Abstract
The scope of this investigation was to establish the prevalence of diabetic foot amputations and analyze associations with factors related to the individual and to primary health care. It is a cross-sectional epidemiological study and the sample included 214 inpatients with diabetic feet in one of the four hospitals specialized in vascular surgery in the state of Pernambuco. Data were collected using semi-structured questionnaires. In the data analysis, chi-square association, Poisson regression (p < 0.05) and descriptive statistics procedures were applied. The prevalence of amputation ascertained was 50%. The following factors related to the individual were associated with its occurrence: low education (p = 0.027); two or more people living in the household (p = 0.046); and patient income below the minimum wage (p = 0.004). The following factors related to primary health care were associated with amputation: not having feet examined (PR = 1.17); not receiving guidance on foot care (PR = 2.24) in consultations in the past year; not using the drug for DM control as prescribed (PR = 1.60); and inadequate glycemic control (PR = 1.83). Understanding these factors helps to identify aspects of preventive care that require improvement.
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Rosa R, Nita ME, Rached R, Donato B, Rahal E. Estimated hospitalizations attributable to Diabetes Mellitus within the public healthcare system in Brazil from 2008 to 2010: study DIAPS 79. Rev Assoc Med Bras (1992) 2014; 60:222-30. [DOI: 10.1590/1806-9282.60.03.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Accepted: 09/01/2014] [Indexed: 11/21/2022] Open
Abstract
Objective: to estimate the number of hospitalizations attributable to diabetes mellitus (DM) and its complications within the public healthcare system in Brazil (SUS) and the mean cost paid per hospitalization. Methods: the official database from the Hospital Information System of the Unified Health System (SIH/SUS) was consulted from 2008 to 2010. The proportion of hospitalizations attributable to DM was estimated using attributable risk methodology. The mean cost per hospitalization corresponds to direct medical costs in nursing and intensive care, from the perspective of the SUS. Results: the proportion of hospitalizations attributable to DM accounted for 8.1% to 12.2% of total admissions in the period, varying according to use of maximum (self-reported with correction factor) or minimal (self-reported) DM prevalence. The hospitalization rate was 47 to 70.8 per 10.000 inhabitants per year. The mean cost per hospitalization varied from 1.302 Brazilian Reais (BRL) to 1,315 BRL. Assuming the maximum prevalence, hospitalizations were distributed as 10.3% as DM itself, 36.6% as chronic DM-associated complications and 53.1% as general medical conditions. Advancing age was accompanied by an increase in hospitalization rates and corresponding costs, and more pronounced in male patients. Conclusion: the results express the importance of DM in terms of the use of health care resources and demonstrate that studies of hospitalizations with DM as a primary diagnosis are not sufficient to assess the magnitude of the impact of this disease.
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Affiliation(s)
- Roger Rosa
- Federal University of Rio Grande do Sul, Brazil
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dos Santos VCF, Kalsing A, Ruiz ENF, Roese A, Gerhardt TE. [A profile of admittances to hospital due to non-contagious chronic diseases sensitive to primary health care among chronologically advantaged patients in the southern half of Rio Grande do Sul]. Rev Gaucha Enferm 2013; 34:124-31. [PMID: 24344594 DOI: 10.1590/s1983-14472013000300016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The purpose here established was that of establishing, within the municipalities in the southern part of the Brazilian State of Rio Grande do Sul, the profile of admittances to hospital resulting from Non-Contagious Chronic Diseases Sensitive to Primary Health Care (NCCDSPHC) among chronologically advantaged patients. This is a transversal study with secondary data obtained from the Information Technology Department of the Brazilian Public Health System--SUS (DATASUS), including variables related to admittance to hospital and also the mortality rates in hospitals (according to causes, gender, age, and time spent in hospital). The NCCDSPHC are responsible for 43.99% of hospital admittances for all causes (AAC), with Pulmonary Diseases standing out as the most prevalent single group (18%), followed by Heart Failure (12.28%). The female sex, with the exception of the Pulmonary Disease category, is the one that causes most admittances to hospital through other causes. We also found a linear trend towards an increase in the mortality rate of the NCCDSPHC when grouped together Our conclusion is that, due to the magnitude of the admittances to hospital, as also the increase in the mortality caused by the NCCDSPHC, it is urgent to embark on more in-depth considerations about care to be taken as part of primary care for the chronologically advantaged in this region.
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Affiliation(s)
| | - Alice Kalsing
- Residente Programa de Residência Multiprofissional e em Area Profissional da Saude, Brasil
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Mattos PE, Luz LL, Santiago LM, Mattos IE. Tendência da mortalidade por diabetes melito em capitais brasileiras, 1980-2007. ACTA ACUST UNITED AC 2012; 56:39-46. [DOI: 10.1590/s0004-27302012000100007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 01/23/2012] [Indexed: 03/13/2023]
Abstract
OBJETIVO: Analisar o padrão de mortalidade por diabetes nas capitais brasileiras entre 1980 e 2007. MATERIAIS E MÉTODOS: Foram calculadas taxas de mortalidade quadrienais e anuais, padronizadas por idade pela população mundial. Modelos de regressão linear foram estimados para análise da tendência nas capitais. RESULTADOS: No primeiro quadriênio, a taxa mais elevada correspondeu a 42,89/100.000 em Aracaju e, no último, a 54,38/100.000 em São Luís. Foram observadas tendências estatisticamente significativas de incremento na maioria das capitais, embora com diferenças regionais. Belo Horizonte foi a única capital a mostrar tendência de declínio. CONCLUSÕES: Uma parte do incremento observado poderia ser atribuída a melhoras no acesso ao diagnóstico e na certificação da causa de morte, porém diferenças regionais na prevalência de fatores de risco e proteção para a doença possivelmente também estão implicadas. A não disponibilidade de série histórica de casos incidentes impossibilita determinar se esses resultados refletem tendências atuais da incidência do diabetes no Brasil.
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Bahia LR, Araujo DV, Schaan BD, Dib SA, Negrato CA, Leão MPS, Ramos AJS, Forti AC, Gomes MB, Foss MC, Monteiro RA, Sartorelli D, Franco LJ. The costs of type 2 diabetes mellitus outpatient care in the Brazilian public health system. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2011; 14:S137-S140. [PMID: 21839888 DOI: 10.1016/j.jval.2011.05.009] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE The prevalence of type 2 diabetes has shown a significant increase in parallel with health care costs. The objective of the Brazilian Study on Diabetes Costs (ESCUDI study) was to estimate direct and indirect costs of type 2 diabetes outpatient care in the Brazilian Public Health Care System. METHODS Data were collected from different levels of health care in eight Brazilian cities in 2007. A total of 1000 outpatients were interviewed and had their medical records data analyzed. Direct medical costs included expenses with medications, diagnostic tests, procedures, blood glucose test strips, and office visits. Nonmedical direct costs included expenses with diet products, transportation, and caregivers. Absenteeism, sick leave, and early retirement were classified as indirect costs. RESULTS Total annual cost for outpatient care was US$2108 per patient, out of which US$1335 per patient of direct costs (63.3%) and US$773 per patient of indirect costs (36.7%). Costs escalated as duration of diabetes and level of health care increased. Patients with both microvascular and macrovascular complications had higher costs (US$3199 per patient) compared to those with either microvascular (US$2062 per patient) or macrovascular (US$2517 per patient) complications only. The greatest portion of direct costs was attributed to medication (48.2%). CONCLUSIONS Diabetes treatment leads to elevated costs both to Brazilian Public Health Care System and society. Costs increased along with duration of disease, level of care and presence of chronic complications, which suggested a need to reallocate health resources focusing on primary prevention of diabetes and its complications.
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Affiliation(s)
- Luciana R Bahia
- Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.
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Moraes SAD, Freitas ICMD, Gimeno SGA, Mondini L. [Diabetes mellitus prevalence and associated factors in adults in Ribeirão Preto, São Paulo, Brazil, 2006: OBEDIARP Project]. CAD SAUDE PUBLICA 2010; 26:929-41. [PMID: 20563393 DOI: 10.1590/s0102-311x2010000500015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 03/11/2010] [Indexed: 02/06/2023] Open
Abstract
To identify diabetes mellitus prevalence and associated factors, a cross-sectional epidemiological study was developed including participants aged 30 years and older living in Ribeirão Preto, São Paulo State, Brazil. Using three-stage cluster sampling, probability weights were applied, resulting in a weighted sample of 2,197 participants. Diabetes mellitus diagnosis was based on previous medical history or World Health Organization (WHO) cut-offs after oral glucose tolerance test. To investigate associated factors, crude and adjusted prevalence ratios were estimated by points and confidence intervals, using Poisson regression. Diabetes mellitus prevalence was 15.02%. After adjusting for potential confounding, factors associated with diabetes mellitus in the final model were: age; family history of diabetes mellitus; waist hip ratio; waist height ratio; number of medicines taken; and use of outpatient services. The results showed high diabetes mellitus prevalence and identified associated factors amenable to intervention.
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Affiliation(s)
- Suzana Alves de Moraes
- Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
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Almino MAFB, Queiroz MVO, Jorge MSB. Diabetes mellitus na adolescência: experiências e sentimentos dos adolescentes e das mães com a doença. Rev Esc Enferm USP 2009; 43:760-7. [DOI: 10.1590/s0080-62342009000400004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
O aumento de doenças crônicas entre crianças e adolescentes, especialmente a Diabetes mellitus, requer conhecimentos que integrem os cuidados à saúde e a integração do indivíduo ao seu meio social. O objetivo foi compreender as experiências e os sentimentos de adolescentes e de suas mães sobre a condição de ser diabético, o tratamento e os cuidados à saúde. Realizamos entrevista semiestruturada com oito adolescentes e sete mães em um serviço público de Barbalha - Ceará - Brasil. A análise dos discursos resultou nas categorias: Sentimentos expressos diante da descoberta da doença; A convivência com a doença e as implicações psicossociais; Mudanças no estilo de vida. As dificuldades dos adolescentes induzem à reflexões sobre comportamentos e adaptações ao novo modo de ser e ao autocuidado. Há necessidade de um cuidado integrando as dimensões físicas e psicossociais de modo a melhorar a assistência ao adolescente e à sua família.
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Rosa TEDC, Bersusa AAS, Mondini L, Saldiva SRDM, Nascimento PR, Venancio SI. Integralidade da atenção às doenças cardiovasculares e diabetes mellitus: o papel da regionalização do Sistema Único de Saúde no estado de São Paulo. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2009. [DOI: 10.1590/s1415-790x2009000200006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Analisar indicadores de estrutura, processo e de resultados da atenção à saúde do adulto, especificamente de Diabetes Mellitus (DM) e Hipertensão Arterial (HA), à luz da regionalização do Sistema Único de Saúde no estado de São Paulo. MÉTODOS: As análises foram realizadas para cinco Regionais de Saúde. Foram analisados os indicadores de estrutura (Índice de Desenvolvimento Humano, índices de hospitais, de leitos de UTI, de ambulatórios, de recursos humanos e tipo de gestão), de processo (cobertura de Estratégia Saúde da Família [ESF], cobertura de consultas básicas e especializadas, índice de invasão/evasão e esforço gestor) e de resultado (% de mortalidade precoce por Acidente Vascular Cerebral, Infarto Agudo do Miocárdio, Insuficiência Cardíaca e por complicações de DM). RESULTADOS: A Regional de Mogi das Cruzes apresentou os valores mais elevados das taxas de mortalidade para os quatro eventos estudados e também quanto à proporção de mortalidade precoce. Em relação a este último indicador, a Regional de Rio Preto apresentou o menor valor entre as Regionais de Saúde estudadas, o que poderia estar relacionado com a adequação da oferta de serviços, maior cobertura da ESF e de consultas básicas e especializadas, além de iniciativas para o fortalecimento de mecanismos formais de pactuação regional. CONSIDERAÇÕES FINAIS: A integralidade da atenção nesta linha de cuidado parece depender de um desenho tecnicamente adequado para a efetividade do referenciamento dos serviços e de práticas adequadas de gestão e de cuidado.
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