Cláudia Brito

Adherence to hormone therapy among women with breast cancer

BackgroundDespite the excellent results obtained with hormone therapy, the long treatment period and the side effects associated with its use make patient adherence difficult. Moreover, certain aspects of health care can mitigate or exacerbate non-adherence. This study aimed to identify the factors associated with adherence to hormone therapy for breast cancer, with the goal of contributing to the reformulation of the care process and to improvements in outcomes.MethodThis was a retrospective longitudinal study based on secondary data. The study integrated and analyzed data from a cohort of 5,861 women with breast cancer who were identified in the databases of the Brazilian National Cancer Institute [Instituto Nacional de Câncer - INCA] and the Unified Health System [Sistema Único de Saúde - SUS]. All of the patients were treated at INCA, which dispenses free medication, and the follow-up period lasted from 01/01/2004 to 10/29/2010. The outcome of interest was hormone treatment adherence, which was defined as the possession of medication, and a logistic regression model was employed to identify the socio-demographic, behavioral, clinical, and health care variables that were independently associated with the variations in this outcome.ResultsThe proportion of women who adhered to hormone therapy was 76.3%. The likelihood of adherence to hormone therapy increased with each additional year of age, as well as among women with a secondary or higher level education, those with a partner, those who underwent surgery, those who had more consultations with a breast specialist and clinical oncologist, and those who underwent psychotherapy; the effect for the latter increased with each additional consultation. Conversely, the likelihood of adherence was lower among patients at a non-curable stage, those who were alcohol drinkers, those who received chemotherapy, those who had undergone more tests and had more hospitalizations, and those who used tamoxifen and combined aromatase inhibitors.ConclusionThis study shows that approximately a quarter of the women with breast cancer did not adhere to hormone treatment, thus risking clinical responses below the expected standards. It also identifies the most vulnerable subgroups in the treatment process and the aspects of care that provide better results.

Use of clinical guidelines and the results in primary healthcare for hypertension

This study aimed to identify strategies to implement clinical guidelines for hypertension in a primary healthcare unit, focusing on the effects of the Family Health Program (FHP) and government Pharmaceutical Home Delivery Program (PHDP) on adherence to guidelines by health professionals and the results of care. The data were obtained from a registry of 5,499 hypertensive patients, stratified according to registration in the FHP and PHDP. The random selection procedure resulted in samples of 150 patient charts in three strata and one stratum (without the FHP or PHDP) with only 22 patient charts. Descriptive statistics and linear regression models were obtained, incorporating the structural information from the sample design (sample strata and weight). Based on information recorded on the patient charts, adherence to clinical guidelines was extremely low. A positive effect had been expected from the FHP and PHDP in terms of adherence to clinical guidelines and results of care. A trend towards a positive effect was observed for the PHDP and a slightly favorable performance for the FHP for adherence to clinical guidelines.

Sobrevida de mulheres tratadas por câncer de mama no estado do Rio de Janeiro

OBJECTIVE To assess the association between breast cancer survival and infrastructure and practices of cancer care units. METHODS Retrospective longitudinal study based on data from the Brazilian information system of authorizations for highly complex cancer procedures covered by the National Health System and a sample of 310 medical records of prevalent breast cancer cases attended at 15 inpatient and outpatient cancer care units providing chemotherapy between 1999 and 2002 in the state of Rio de Janeiro, Southeastern Brazil. Independent variables were infrastructure of cancer units, interventions, and sociodemographic and clinical characteristics of women. Kaplan-Meier method and Cox proportional hazards model (pseudolikelihood) were used for data analysis. RESULTS Kaplan-Meier analyses pointed out significant associations between survival and time between diagnosis and treatment start, surgery, hormone therapy, type of adjuvant hormone therapy, therapy combinations, type of care unit and health insurance, unit size and category. Estimates obtained from the Cox model showed positive associations between hazard of death and time between diagnosis and treatment, unit size and type combined to use of health insurance, and negative associations between survival and surgery and type of hormone therapy. CONCLUSIONS The study findings show an association between breast cancer survival and health care provided by affiliated services with practical implications for policy making for cancer control in Brazil.OBJETIVO: Avaliar a associacao entre sobrevida de mulheres com câncer de mama e estrutura e praticas observadas nos estabelecimentos de assistencia oncologica. METODOS: Estudo longitudinal retrospectivo, baseado em informacoes do Sistema de Autorizacao de Procedimentos de Alta Complexidade do Sistema Unico de Saude e em amostra aleatoria de 310 prontuarios de mulheres prevalentes atendidas em 15 unidades hospitalares e ambulatoriais oncologicas com quimioterapia entre 1999 e 2002, no estado do Rio de Janeiro. Foram consideradas como variaveis independentes caracteristicas da estrutura das unidades oncologicas e as suas intervencoes praticadas, controlando o efeito com variaveis sociodemograficas e clinicas das pacientes. Para analise dos dados, foram utilizados a tecnica de Kaplan-Meier e o modelo de risco de Cox (pseudo-verossimilhanca). RESULTADOS: As analises de Kaplan-Meier apontaram associacoes significativas entre sobrevida e tempo entre diagnostico e inicio do tratamento, realizacao de cirurgia, utilizacao de hormonioterapia, tipo de hormonioterapia, combinacoes terapeuticas, tipo de unidade e plano de saude, volume de atendimento em câncer de mama do estabelecimento e natureza juridica da unidade. Estimativas obtidas pelo modelo de Cox indicaram associacoes positivas entre o hazard de morte e tempo entre diagnostico e inicio do tratamento, volume de atendimento de câncer de mama do estabelecimento e tipo de unidade combinado ao uso de plano de saude; e negativas entre sobrevida e cirurgia de mama e tipo de hormonioterapia. CONCLUSOES: Os resultados mostram associacao entre sobrevida de câncer de mama e o cuidado de saude prestado pelos servicos credenciados, com implicacoes praticas para pautar novas propostas para o controle do câncer no Brasil.

DOTS in primary care units in the city of Rio de Janeiro, Southeastern Brazil

OBJETIVO: Descrever a implantacao e os efeitos do directly-observed treatment short course (DOTS) em centros municipais de saude. METODOS: Foram realizadas entrevistas com profissionais dos nove centros municipais de saude que ofereciam DOTS no Rio de Janeiro, RJ, em 2004-2005. Foram coletados os dados de todos os centros municipais de saude da cidade sobre os tratamentos de tuberculose iniciados em 2004. Analises bivariadas e modelo multinomial foram aplicados para identificar associacoes entre resultados do tratamento e variaveis demograficas e relativas ao processo de tratamento, incluindo estar em DOTS ou terapia auto-administrada (SAT). RESULTADOS: Dos 4.598 casos de tuberculose tratados, 1.118 (24,3%) utilizaram DOTS e 3.480 (75,7%), SAT. As chances de uso de DOTS foram maiores entre pacientes com menos de 50 anos, recidiva de tuberculose, historia previa de abandono ou falencia de tratamento. As chances de morte foram 52,0% maiores entre pacientes em DOTS comparados aqueles em SAT. A modalidade de tratamento com maior sucesso foi DOTS com agentes comunitarios de saude. Foi observada reducao de 21,0% na razao de chances de abandono (vs. cura) entre pacientes em DOTS, comparados a pacientes em SAT, e reducao de 64,0% entre pacientes em DOTS com ACS, comparados aqueles sem. CONCLUSOES: Pacientes com perfil de menor adesao ao tratamento tenderam a ser incluidos em DOTS. Essa estrategia melhora a qualidade da atencao provida a pacientes com tuberculose, ainda que metas propostas nao tenham sido atingidas.

Survival of breast cancer women in the state of Rio de Janeiro, Southeastern Brazil

OBJECTIVE To assess the association between breast cancer survival and infrastructure and practices of cancer care units. METHODS Retrospective longitudinal study based on data from the Brazilian information system of authorizations for highly complex cancer procedures covered by the National Health System and a sample of 310 medical records of prevalent breast cancer cases attended at 15 inpatient and outpatient cancer care units providing chemotherapy between 1999 and 2002 in the state of Rio de Janeiro, Southeastern Brazil. Independent variables were infrastructure of cancer units, interventions, and sociodemographic and clinical characteristics of women. Kaplan-Meier method and Cox proportional hazards model (pseudolikelihood) were used for data analysis. RESULTS Kaplan-Meier analyses pointed out significant associations between survival and time between diagnosis and treatment start, surgery, hormone therapy, type of adjuvant hormone therapy, therapy combinations, type of care unit and health insurance, unit size and category. Estimates obtained from the Cox model showed positive associations between hazard of death and time between diagnosis and treatment, unit size and type combined to use of health insurance, and negative associations between survival and surgery and type of hormone therapy. CONCLUSIONS The study findings show an association between breast cancer survival and health care provided by affiliated services with practical implications for policy making for cancer control in Brazil.OBJETIVO: Avaliar a associacao entre sobrevida de mulheres com câncer de mama e estrutura e praticas observadas nos estabelecimentos de assistencia oncologica. METODOS: Estudo longitudinal retrospectivo, baseado em informacoes do Sistema de Autorizacao de Procedimentos de Alta Complexidade do Sistema Unico de Saude e em amostra aleatoria de 310 prontuarios de mulheres prevalentes atendidas em 15 unidades hospitalares e ambulatoriais oncologicas com quimioterapia entre 1999 e 2002, no estado do Rio de Janeiro. Foram consideradas como variaveis independentes caracteristicas da estrutura das unidades oncologicas e as suas intervencoes praticadas, controlando o efeito com variaveis sociodemograficas e clinicas das pacientes. Para analise dos dados, foram utilizados a tecnica de Kaplan-Meier e o modelo de risco de Cox (pseudo-verossimilhanca). RESULTADOS: As analises de Kaplan-Meier apontaram associacoes significativas entre sobrevida e tempo entre diagnostico e inicio do tratamento, realizacao de cirurgia, utilizacao de hormonioterapia, tipo de hormonioterapia, combinacoes terapeuticas, tipo de unidade e plano de saude, volume de atendimento em câncer de mama do estabelecimento e natureza juridica da unidade. Estimativas obtidas pelo modelo de Cox indicaram associacoes positivas entre o hazard de morte e tempo entre diagnostico e inicio do tratamento, volume de atendimento de câncer de mama do estabelecimento e tipo de unidade combinado ao uso de plano de saude; e negativas entre sobrevida e cirurgia de mama e tipo de hormonioterapia. CONCLUSOES: Os resultados mostram associacao entre sobrevida de câncer de mama e o cuidado de saude prestado pelos servicos credenciados, com implicacoes praticas para pautar novas propostas para o controle do câncer no Brasil.

Clinical and demographic data concordance comparing authorizations for high-complexity oncological procedures and patient records of women treated under the Unified National Health System in Rio de Janeiro, Brazil

This study investigates the concordance of clinical and demographic data under the Unified National Health System (SUS) in Brazil, comparing authorizations for high-complexity oncological procedures in breast cancer with a random sample of 310 corresponding medical records in Rio de Janeiro State, Brazil. Concordance was verified using kappa (K), prevalence-adjusted bias-adjusted kappa (PABAK), weighted-kappa (KW), intra-class correlation (ICC), and relative frequency statistics. 95% confidence intervals were estimated, and Landis and Koch criteria were applied for concordance interpretation. Assuming PABAK as the most appropriate statistic for the variables analyzed, we observed a moderate concordance for cancer staging, PABAK = 0.63 (95%CI: 0.56-0.70), and for morphological diagnosis, PABAK = 0.84 (95%CI: 0.72-0.96). For date of birth and date of diagnosis, ICCs were 0.96 (95%CI: 0.95-0.96) and 0.92 (95%CI: 0.90-0.94), respectively. Concordance regarding municipality of residence was 52.9%. The study indicates that, except for municipality of residence, the data concordance comparing authorizations for procedures and patient medical records in Rio de Janeiro allows its application to epidemiological and health services research, as well as for health planning purposes.

Tuberculosis Control Program and patient satisfaction, Rio de Janeiro, Brazil

OBJECTIVE To evaluate factors associated with users’ satisfaction in the Tuberculosis Control Program. METHODS A cross-sectional study of 295 patients aged ≥ 18 years, with two or more outpatient visits in the Tuberculosis Control Program, in five cities in the metropolitan region of Rio de Janeiro, RJ, Southeastern Brazil, in 2010. Considering an estimated population of 4,345 patients, the sampling plan included 15 health care units participating in the program, divided into two strata: units in Rio de Janeiro City, selected with probability proportional to the monthly average number of outpatient visits, and units in the other four cities. In the units, four temporal clusters of five patients each were selected with equal probability, totaling 300 patients. A questionnaire investigating the users’ clinical and sociodemographic variables and aspects of care and service in the program relevant to user satisfaction was applied to the patients. Descriptive statistics about users and their satisfaction with the program were obtained, and the effects of factors associated with satisfaction were estimated. RESULTS Patients were predominantly males (57.7%), with a mean age of 40.9 and with low level of schooling. The mean treatment time was 4.1 months, mostly self-administered (70.4%). Additionally, 25.8% had previously been treated for tuberculosis. There was a high level of satisfaction, especially regarding medication provision, and respect to patients by the health professionals. Patients who were younger (≤ 30), those on self-administered treatment, and with graduate level, showed less satisfaction. Suggestions to improve the services include having more doctors (70.0%), and offering exams in the same place of attendance (55.1%). CONCLUSIONS Patient satisfaction with the Tuberculosis Control Program was generally high, although lower among younger patients, those with university education and those on self-administered treatment. The study indicates the need for changes to structural and organizational aspects of care, and provides practical support for its improvement.

Fatores associados à persistência à terapia hormonal em mulheres com câncer de mama

OBJECTIVE To analyze factors associated with persistence to breast cancer hormone therapy in order to contribute to the quality of care improvement. METHODS Retrospective longitudinal study, based on secondary data. A cohort of 5,861 women with breast cancer registered in different datasets of the Brazilian National Cancer Institute and the Brazilian Unified Health System were analyzed. All women were treated at this hospital, which provides free medication, and the follow-up period was from January 2004 to October 2010. Sociodemographic, behavioral, and clinical variables, as well as aspects of lifestyle and health care, were considered in the explanation of variations in the persistence to hormone therapy, applying the Kaplan-Meier method and the Cox proportional hazard model. RESULTS Overall persistence to hormone therapy was 79.0% at the end of the first year, and 31.0% in five years of treatment. The risk of discontinuing hormone therapy was higher among women under 35 years old, with more advanced disease (stages III and IV), alcohol drinkers, those undergoing chemotherapy, and for each additional hospitalization, exam performed, and month between diagnosis and beginning of treatment. In the opposite direction, the risk of discontinuity was lower among women who had at least finished high school, those with partner, with a family history of cancer, those who had undergone breast surgery, and who had outpatient visits to a Mastologist, and a Clinical Oncologist. CONCLUSIONS The majority of the women with breast cancer (69.0%) do not persist with hormone treatment for the five years recommended, increasing the risk of inadequate clinical results. The results show aspects of care that can provide better results.

Utilização de diretrizes clínicas em cardiologia na saúde suplementar no Brasil

BACKGROUND: The objective of this study is to present cardiovascular results of a national study about the implementation of clinical guidelines and other instruments and practices for clinical care management among health plan operators in Brasil. METHODS: This was a cross-sectional study based on a representative sample of the 1,573 Brazilian health plan operators, stratified by macro region and market segment. Each stratum was subdivided in take-all and take-some strata by Hedlins method, with equiprobability selection in each take-some stratum. The resulting sample size was of 90 health plan operators who were interviewed using a structured questionnaire. The study had a descriptive nature and, to obtain estimates for percents and total number of health plan operators relative to a population size of N=1572., sample weights were taken into account. RESULTS: Of the health plan operators, 61.2% considered that the implementation of clinical guidelines should be conducted by administrative and regulatory government organizations, involving a partnership with health plan operators, health service providers and medical societies. It was shown that only 32.3% of the health plan operators in the country enforce clinical guidelines. With regard to cardiovascular disease, the reported utilization of guidelines was one of the highest among all diseases analyzed. The percentages for acute myocardial infarction (87%), congestive heart failure (85%) and the use of invasive procedures (81.1%) were higher than for arterial hypertension (74.1%) and cerebrovascular disease (72.2%). CONCLUSION: This study indicated the incipient utilization of clinical guidelines among health plan operators in the Brazilian health system. In general, the cardiovascular area showed one of the highest rates of utilization reported in the study.

Diretrizes clínicas e outras práticas voltadas para a melhoria da qualidade assistencial em operadoras de planos de saúde sob a perspectiva dos seus dirigentes, no Brasil

This study aimed to characterize the implementation of clinical guidelines and other instruments and practices for health care quality improvement among health plan operators in Brazil. It was a national cross-sectional descriptive study, initially considering 1,573 health plan operators registered in the National Agency for Supplementary Health Care. The sample design was complex, stratified by macro-region, market segment, and number of beneficiaries. Ninety health plan operators agreed to participate and were interviewed. To obtain estimates for the universe of health plan operators, a sample expansion factor attributed per stratum was considered. Only 32.3% of the health plan operators implemented clinical guidelines, with important variation across regions and market segments. Clinical governance practices are still in the very initial stages. Challenges are presented with regard to health care incorporation as a dimension of management within health care organizations, including health plan operators. Initiatives to improve quality of care need to be integrated and conducted at the organizational level.