Anneliese Domingues Wysocki

Retardo no diagnóstico da tuberculose em município da tríplice fronteira Brasil, Paraguai e Argentina

OBJETIVO: Identificar os aspectos relacionados aos doentes e aos servicos de saude no retardo do diagnostico da tuberculose. METODOS: Estudo epidemiologico em Foz do Iguacu, Parana, Brasil, realizado em 2009. Utilizou-se o instrumento The Primary Care Assessment Tool adaptado para a avaliacao da atencao a tuberculose. Empregaram-se tambem tecnicas de estatistica descritiva, como analise de frequencia, medidas de posicao (mediana e intervalos interquartis) e odds. RESULTADOS: Houve retardo na busca por servicos de saude entre aqueles na faixa etaria > 60 anos, sexo feminino, baixa escolaridade e conhecimento precario sobre a doenca. As variaveis clinicas caso novo e infeccao por HIV e as variaveis comportamentais uso de cigarros e bebidas alcoolicas nao estiveram relacionadas ao retardo no diagnostico. O tempo para o diagnostico atribuido ao doente e ao servico de saude foi de 30 e 10 dias (mediana), respectivamente. O Pronto Atendimento 24 Horas e a Atencao Primaria a Saude nao foram efetivos para a suspeicao de tuberculose e solicitacao de exames de apoio diagnostico, com alto percentual de encaminhamento para o ambulatorio do Programa de Controle da Tuberculose. CONCLUSOES: A procura pela Atencao Primaria a Saude para o diagnostico resultou em maior tempo ate a descoberta da doenca. O ambulatorio do Programa de Controle da Tubercu lose apresentou desempenho mais efetivo para o diagnostico da tuberculose devido ao preparo da equipe e ao acolhimento ordenado com oferta de exames de apoio diagnostico.

Atraso na busca por serviço de saúde para o diagnóstico da tuberculose em Ribeirão Preto (SP)

The scope of this paper is to analyze delays in locating health services for the diagnosis of tuberculosis in Ribeirao Preto in 2009. An epidemiological and cross-sectional study was conducted with 94 TB patients undergoing treatment. A structured questionnaire, based on the Primary Care Assessment Tool adapted for TB care was used. A median (15 days or more) was established to characterize delay in health attendance. Using the Prevalence Ratio, the variables associated with longer delay were identified. The first healthcare services sought were the Emergency Services (ES) (57.5%). The longest period between seeking assistance occurred among males, aged between 50 and 59, who earned less than five minimum wages, had pulmonary TB, were new cases, were not co-infected with TB/HIV, did not consume alcohol, had satisfactory knowledge about TB before diagnosis (with a statistically significant association with delay) and who did not seek healthcare close to home before developing TB. There is a perceived need for training healthcare professionals about the signs and symptoms of the disease, reducing barriers of access to timely diagnosis of TB and widely disseminating it to the community in general.

The epidemiological dimension of TB/HIV co-infection

This study aimed to analyze the epidemiological indicators of TB/HIV co-infection in São José do Rio Preto, São Paulo, Brazil from 1998 to 2006. Data of new TB cases that initiated treatment between January 1998 and December 2006 were obtained from the TB Notification System (EPI-TB) and 306 cases were reported. The incidence rate was 5.1/100,000 inhabitants in 2006. Most cases were men (72.5%) with ages ranging between 20 and 59 years (96.4 %). The majority (51%) had incomplete primary education. Pulmonary TB was the most common type (52.9%) and 46.1% of the patients received supervised treatment. In 2006, the cure rate was 33.3%, 14.3% death rate and no patient abandoned the treatment. Diagnosis occurred at the hospital in 60% of the cases. Results show the need of improved coordination between the citys Tuberculosis Control Program and the Sexually Transmitted Diseases and HIV Program.El objetivo fue analizar los indicadores epidemiologicos de la coinfeccion tuberculosis y virus de la inmunodeficiencia humana (TB/VIH) en el municipio de Sao Jose del Rio Preto, Sao Paulo, Brasil, en el periodo de 1.998 a 2.006. Los datos de los casos nuevos de TB, que iniciaron el tratamiento entre enero de 1.998 y diciembre de 2.006, fueron recolectados del Sistema de Notificacion de la TB (EPI-TB). Fueron notificados 306 casos. El coeficiente de incidencia fue de 5,1/100.000 hab, en 2006. Hubo predominio de personas del sexo masculino (72,5%), en el intervalo de edad de 20 a 59 anos (96,4%). La mayoria (51%) no poseia la ensenanza fundamental completa. La forma clinica pulmonar fue relevante (52,9%) y recibieron tratamiento supervisado 46,1% enfermos. En 2.006, la tasa de cura fue de 33,3%, de muertes 14,3%, y no hubo ningun caso de abandono. Entre los casos, 60% fueron diagnosticados en el hospital. Los datos reflejan la necesidad de tener una mayor articulacion entre el Programa Municipal de Control de la Tuberculosis y el Programa Municipal de DST/SIDA.

A dimensão epidemiológica da coinfecção TB/HIV

This study aimed to analyze the epidemiological indicators of TB/HIV co-infection in São José do Rio Preto, São Paulo, Brazil from 1998 to 2006. Data of new TB cases that initiated treatment between January 1998 and December 2006 were obtained from the TB Notification System (EPI-TB) and 306 cases were reported. The incidence rate was 5.1/100,000 inhabitants in 2006. Most cases were men (72.5%) with ages ranging between 20 and 59 years (96.4 %). The majority (51%) had incomplete primary education. Pulmonary TB was the most common type (52.9%) and 46.1% of the patients received supervised treatment. In 2006, the cure rate was 33.3%, 14.3% death rate and no patient abandoned the treatment. Diagnosis occurred at the hospital in 60% of the cases. Results show the need of improved coordination between the citys Tuberculosis Control Program and the Sexually Transmitted Diseases and HIV Program.El objetivo fue analizar los indicadores epidemiologicos de la coinfeccion tuberculosis y virus de la inmunodeficiencia humana (TB/VIH) en el municipio de Sao Jose del Rio Preto, Sao Paulo, Brasil, en el periodo de 1.998 a 2.006. Los datos de los casos nuevos de TB, que iniciaron el tratamiento entre enero de 1.998 y diciembre de 2.006, fueron recolectados del Sistema de Notificacion de la TB (EPI-TB). Fueron notificados 306 casos. El coeficiente de incidencia fue de 5,1/100.000 hab, en 2006. Hubo predominio de personas del sexo masculino (72,5%), en el intervalo de edad de 20 a 59 anos (96,4%). La mayoria (51%) no poseia la ensenanza fundamental completa. La forma clinica pulmonar fue relevante (52,9%) y recibieron tratamiento supervisado 46,1% enfermos. En 2.006, la tasa de cura fue de 33,3%, de muertes 14,3%, y no hubo ningun caso de abandono. Entre los casos, 60% fueron diagnosticados en el hospital. Los datos reflejan la necesidad de tener una mayor articulacion entre el Programa Municipal de Control de la Tuberculosis y el Programa Municipal de DST/SIDA.

Diagnóstico da tuberculose: desempenho do primeiro serviço de saúde procurado em São José do Rio Preto, São Paulo, Brasil

Estudo transversal com objetivo de analisar o desempenho do primeiro servico de saude procurado para o diagnostico da TB pulmonar em Sao Jose do Rio Preto, Sao Paulo, Brasil, em 2009. Foram entrevistados 81 doentes em tratamento. Adotou-se um questionario baseado no Primary Care Assessment Tool, adaptado para atencao a TB, e o referencial de avaliacao dos servicos de saude (estrutura e processo). Os dados foram analisados mediante tecnicas descritivas e analise de correspondencia multipla. O principal servico procurado foi o Pronto Atendimento (UPA) (49,4%) e o que mais diagnosticou os casos de TB foi o hospital (39,5%) e a atencao basica (30,9%). Os servicos especializados apresentaram associacao com o melhor desempenho no diagnostico e a UPA com o pior. A atencao basica associou-se com desempenho intermediario e fragilidades na estrutura. O alcance de uma deteccao eficaz dos casos de TB nas principais portas de entrada perpassa pela melhoria na suspeicao, reforcando a necessidade de investimentos da gestao na capacitacao dos recursos humanos para a identificacao dos sintomaticos respiratorios.

Validity and reliability of a health care service evaluation instrument for tuberculosis

OBJECTIVE To evaluate the validity and reliability of an instrument that evaluates the structure of primary health care units for the treatment of tuberculosis. METHODS This cross-sectional study used simple random sampling and evaluated 1,037 health care professionals from five Brazilian municipalities (Natal, state of Rio Grande do Norte; Cabedelo, state of Paraíba; Foz do Iguaçu, state of Parana; Sao José do Rio Preto, state of Sao Paulo, and Uberaba, state of Minas Gerais) in 2011. Structural indicators were identified and validated, considering different methods of organization of the health care system in the municipalities of different population sizes. Each structure represented the organization of health care services and contained the resources available for the execution of health care services: physical resources (equipment, consumables, and facilities); human resources (number and qualification); and resources for maintenance of the existing infrastructure and technology (deemed as the organization of health care services). The statistical analyses used in the validation process included reliability analysis, exploratory factor analysis, and confirmatory factor analysis. RESULTS The validation process indicated the retention of five factors, with 85.9% of the total variance explained, internal consistency between 0.6460 and 0.7802, and quality of fit of the confirmatory factor analysis of 0.995 using the goodness-of-fit index. The retained factors comprised five structural indicators: professionals involved in the care of tuberculosis patients, training, access to recording instruments, availability of supplies, and coordination of health care services with other levels of care. Availability of supplies had the best performance and the lowest coefficient of variation among the services evaluated. The indicators of assessment of human resources and coordination with other levels of care had satisfactory performance, but the latter showed the highest coefficient of variation. The performance of the indicators “training” and “access to recording instruments” was inferior to that of other indicators. CONCLUSIONS The instrument showed feasibility of application and potential to assess the structure of primary health care units for the treatment of tuberculosis.

Early diagnosis of tuberculosis in the health services in different regions of Brazil

13 Objetivo: analisar o primeiro contato do doente com os servicos de saude para o diagnostico oportuno da tuberculose (TB), em diferentes regioes do Brasil. Metodo: trata-se de estudo de coorte transversal, em 6 municipios das Regioes Sudeste, Sul e Nordeste. Para a coleta utilizaram-se fontes secundarias e entrevista com os doentes. Os dados foram analisados por meio de tecnicas descritivas e analise fatorial de correspondencia multipla. Resultados: a Atencao Primaria a Saude apresentou maior tempo e menor proporcao de diagnosticos. Os servicos associados ao diagnostico, na primeira consulta, foram os servicos especializados e os Programas de Controle da TB, que oferecem consulta e exames no proprio local. Conclusao: faz-se necessaria a organizacao do trabalho de forma integrada, entre as equipes dos diferentes servicos, para as acoes de controle da TB. Na Atencao Primaria a Saude, e preciso ainda observar o grau de incorporacao e sustentabilidade na execucao dessas acoes a pratica diaria dos servicos.

Tuberculosis diagnosis and performance assessment of the first health service used by patients in São José do Rio Preto, São Paulo State, Brazil

This cross-sectional study aimed to analyze the first health service to which patients turned for tuberculosis diagnosis in São José do Rio Preto, São Paulo, Brazil, 2009. Eighty-one patients in treatment were interviewed with a questionnaire based on the Primary Care Assessment Tool adapted to TB care and used as a reference for health services performance (structure and process). Data analysis used descriptive and multiple correspondence techniques. Nearly half of the patients initially came to emergency care departments (49.4%), and most TB diagnoses were made in hospitals (39.5%) and primary care services (30.9%). Specialized services were associated with the best diagnostic performance, as opposed to emergency departments, with the worst performance. Primary care services were associated with intermediate performance and weaknesses in infrastructure. The reach of effective detection of TB cases in the portals of entry into the health system involves enhanced diagnostic suspicion, thus emphasizing the need for investments in the management of human resources training for the identification of individuals with respiratory symptoms.

Performance evaluation of primary care services for the treatment of tuberculosis

OBJECTIVE Evaluating the performance of primary care services for the treatment of tuberculosis according to the assessment referential of health services (structure/process) in Cabedelo, a port city in the state of Paraíba. METHOD An evaluation quantitative, cross-sectional study, in which were carried out 117 interviews with health professionals using a structured instrument. The analysis was based on the construction of indicators using a standardized value for the reduced variable (z=1). RESULTS The structural indicators showed regular performance for the following variables: professional training, access to record instruments and coordination with other services. The process indicators related to external actions and information about the disease had unsatisfactory performance. The directly observed treatment and the flows of reference/counter-reference had regular performance. CONCLUSION The focused professional qualification, the fragmentation of practices and the unsystematic home care constitute obstacles for carrying out actions aimed at providing expanded, continuous and resolute care.

Objetivo Avaliar o desempenho dos servicos de Atencao Basica para o tratamento da tuberculose segundo o referencial de avaliacao dos servicos de saude (estrutura/processo) em Cabedelo, municipio portuario da Paraiba. Metodo Pesquisa avaliativa, quantitativa, de corte transversal onde foram realizadas 117 entrevistas com os profissionais de saude, atraves de um instrumento estruturado. A analise pautou-se na construcao de indicadores, utilizando-se valor padronizado para a variavel reduzida (z=1). Resultados Os indicadores estruturais apresentaram desempenho regular para as variaveis: capacitacao profissional; acesso a instrumentos de registro; articulacao com outros servicos. Quanto ao processo, os indicadores relacionados as acoes externas e informacoes sobre a doenca apresentaram desempenho insatisfatorio. O tratamento diretamente observado e os fluxos de referencia/contrarreferencia tiveram desempenho regular. Conclusao A qualificacao profissional focalizada, a fragmentacao das praticas e a atencao domiciliaria assistematica, constituem em obstaculos para o desempenho de acoes voltadas a prestacao do cuidado ampliado, continuo e resolutivo.

Coordenação da assistência prestada às pessoas que vivem com HIV/AIDS em um município do Estado de São Paulo, Brasil

Objetivou-se analisar a coordenacao das acoes e servicos de saude na assistencia as pessoas que vivem com HIV/AIDS. Trata-se de um estudo seccional com 301 pessoas que vivem com HIV/AIDS. A analise foi feita por tecnicas descritivas, analise de variância e comparacao multiplas de medias. Encontrou-se que a coordenacao da assistencia foi satisfatoria (media = 3,69 e DP = 1,74). As pessoas que vivem com HIV/AIDS utilizavam outros servicos de saude alem dos Servicos de Assistencia Especializada em HIV/AIDS – SAE (Pronto Atendimento: 67%; atencao basica: 43,2%; outros servicos especializados: 23,6%; servicos privados: 15%). Os cinco SAE apresentaram diferentes desempenhos, bem como distintos contextos e composicoes assistenciais, entretanto adequado manejo dos aspectos clinicos em detrimento dos sociais. O fornecimento da guia de referencia foi tido como satisfatorio, entretanto a guia de contrarreferencia insatisfatorio. Ha necessidade de estrategias que favorecam o desenvolvimento de acoes compartilhadas e cooperadas dentro das equipes dos SAE e entre os diferentes servicos com o intuito de fortalecer a producao de cuidado resolutivo.The aim of this study was to analyze the coordination of health activities and services for persons living with AIDS. This was a cross-sectional study of 301 persons living with AIDS. The analysis used descriptive techniques, analysis of variance, and multiple comparisons of means. Coordination of care was found to be satisfactory (mean = 3.69 and SD = 1.74). Persons living with AIDS used other health services in addition to the Services for Specialized HIV/AIDS Care (67.0% emergency departments, 43.2% primary care, 23.6% other specialized services, 15% private services). The five specialized HIV/AIDS clinics showed different performance levels as well as distinct contexts and healthcare configurations, but adequate clinical management (comparatively better than management of social issues). Provision of the referral guide was considered satisfactory, but the counter-referral guide was found to be unsatisfactory. Strategies are needed to promote the development of shared and cooperative actions within the healthcare teams in the specialized HIV/AIDS clinics and between the different services in order to strengthen the provision of care with case-resolution capacity.