Daisy Maria Xavier de Abreu

Evaluation of cause-of-death statistics for Brazil, 2002–2004

BACKGROUND Mortality statistics systems with reliable cause-of-death data constitute a major resource for effective health planning; however, many developing countries lack such information systems. Brazil has a long history of registering deaths, and a critical assessment of the quality of current cause-of-death statistics in its five different regions is crucial to identify strengths and weaknesses in the data, and present options for improvement. METHODS Quality of cause-of-death data from 2002 to 2004 was evaluated using an assessment framework based on four main attributes: generalizability, reliability, validity and policy relevance. A set of nine criteria: coverage, completeness, consistency of cause patterns with general mortality levels, consistency of cause specific mortality proportions over time, content validity, proportion of ill-defined causes and non-specific codes, incorrect or improbable age or sex patterns, timeliness, and geographical disaggregation were used to assess the four attributes of data quality. RESULTS Completeness of death registration varies from 72 to 80% in the northeast regions, compared with 85-90% in the Southeast and Centre-West regions, and 94-97% in the wealthier South region. The proportion of ill-defined deaths is an important problem in reported causes of death from almost all regions. Lack of adequate evidence limits the assessment of content validity of registered causes of death. Coverage, consistency of causes with general level of mortality, consistency over time, age and sex patterns, timeliness and usability of statistics for subnational purposes were judged to be reasonable and increase confidence in using the statistics. CONCLUSIONS There is considerable heterogeneity in the quality of cause-of-death statistics across Brazilian regions, especially for criteria such as completeness and ill-defined causes. These factors can influence generalizability and validity of reported causes of death, and must be considered in the interpretation and use of data for secondary descriptive analyses such as burden of disease estimation at regional level, with suitable adjustments to account for bias. The differences identified in this study could be a useful guide for defining measures and investments needed to improve data quality in Brazil.

Relação entre as causas de morte evitáveis por atenção à saúde e a implementação do Sistema Único de Saúde no Brasil

OBJETIVOS: Analisar a relacao entre a ocorrencia de mortes que poderiam ser evitadas por atencao a saude e o processo de reorganizacao do sistema de saude brasileiro entre 1983 e 2002. METODOS: No presente estudo ecologico, a mortalidade por causas evitaveis foi analisada em 117 municipios. As causas de morte evitaveis por atencao a saude foram agrupadas em: evitaveis por diagnostico e tratamento precoce, evitaveis por melhoria no tratamento e na atencao medica e doenca isquemica do coracao. Para avaliar a associacao entre as causas de morte evitaveis e a reorganizacao do sistema de saude, o periodo analisado foi dividido em dois subperiodos, 1983 a 1992 e 1993 a 2002 (antes e depois da aprovacao da norma operacional que serviu como referencial para a implantacao do Sistema Unico de Saude). Utilizou-se um modelo de regressao binomial negativa, com controle das variaveis sexo, idade, regiao geografica e condicoes socioeconomicas. RESULTADOS: No periodo analisado, ocorreram 1 854 165 obitos por causas evitaveis nas idades de 0 a 74 anos nos municipios selecionados. A analise multivariada indicou que o risco foi maior no periodo de 1983 a 1992 em relacao ao periodo de 1993 a 2002 para os tres grupos de causas evitaveis estudados. Observou-se que os homens apresentaram risco maior, particularmente para a doenca isquemica do coracao. As populacoes mais jovens tiveram um risco menor. O nivel socioeconomico mais elevado reduziu o risco de morte por causas evitaveis, exceto para a doenca isquemica do coracao. CONCLUSOES: Os resultados sugerem que, no Brasil, o declinio da mortalidade por causas evitaveis entre 1983 e 2002 deveu-se, em parte, as mudancas na oferta e no acesso aos servicos de saude, impulsionadas pela reorganizacao do sistema de saude a partir da decada de 1990.

Gender differences in avoidable mortality in Brazil (1983-2005)

The aim of the article was to analyze gender differences in mortality in 117 Brazilian municipalities from 1983 to 2005, based on three groups of causes of avoidable death: (1) avoidable through early diagnosis and treatment, (2) avoidable by improvements in quality of treatment and medical care, and (3) ischemic heart disease. The association between avoidable mortality and demographic and socioeconomic conditions and healthcare variables was analyzed through negative binomial regression. The multiple decrement technique was used to evaluate the impact of avoidable causes on life expectancy for men and women. Men showed a higher risk of death for all three groups of avoidable causes, after controlling for selected variables. Women would gain more than men, with an increase of up to five years in life expectancy, if avoidable causes were eliminated by diagnosis and early treatment. Further research is needed in gender-related factors, which may be related to differential mortality rates in men and women.

Abordagem pedagógica e diversificação dos cenários de ensino médico: projetos selecionados pelo PROMED

Este trabalho analisa as principais propostas de abordagem pedagogica e diversificacao de cenarios do processo de ensino apresentadas pelas escolas selecionadas pelo Programa de Incentivo a Mudancas Curriculares nas Escolas de Medicina (Promed), instituido em 2002 pelos ministerios da Saude e da Educacao. Foi realizada pesquisa documental, utilizando-se roteiro com base no termo de referencia do programa para a leitura dos projetos. Verificou-se que todas as escolas selecionadas ja se encontravam em processo de mudanca curricular por ocasiao do edital Promed. Embora buscassem alcancar os objetivos apresentados pelo programa, os projetos selecionados apontaram diferentes caminhos para sua realizacao. Conhecer essas propostas e a maneira como se articularam entre si e com o objetivo final do Promed e de capital importância para os educadores da area de saude envolvidos com mudancas curriculares em suas instituicoes, bem como para os gestores dessa area que vem apresentando suas demandas em consonância com as necessidades de saude da populacao

Mortality differentials between metropolitan areas of Brazil, 1985-1995

OBJETIVO: Analisar a evolucao da mortalidade, por idade e sexo, segundo as causas de morte, nas regioes metropolitanas de Belo Horizonte (RMBH) e Salvador (RMS), entre 1985 e 1995. METODOS: Os dados utilizados foram provenientes do Registro Civil, fornecidos pelo SIM (Sistema de Informacao sobre Mortalidade do Ministerio da Saude). As causas de morte foram classificadas em evitaveis e nao evitaveis. Aplicou-se o metodo de decomposicao de Pollard para analisar a contribuicao, na evolucao dos ganhos de esperanca de vida ao nascer, dos grupos de causas que tiveram um aumento da sua participacao relativa na estrutura da mortalidade. RESULTADOS: O processo de declinio da mortalidade, em curso nas regioes metropolitanas estudadas, vem sofrendo mudancas nas ultimas decadas com uma tendencia a reducao dos diferenciais existentes. No seu conjunto, as causas evitaveis reduziram seu peso relativo em ambas as regioes: na RMBH, de 36,5%, em 1985, para 30,6%, em 1995, entre os homens, e de 34,9%, em 1985, para 28%, em 1995, entre as mulheres. Na RMS, observou-se uma reducao maior da participacao relativa para as mulheres: de 35,4%, em 1985, para 25,9%, em 1995. Para os homens, essa participacao passou de 44% do total, em 1985, para 39,7%, em 1995. CONCLUSOES: Ainda persiste uma estrutura de causas de morte que pode estar indicando que, nas regioes estudadas, os progressos nos niveis de mortalidade nao estao atingindo as populacoes menos favorecidas na intensidade e velocidade esperadas.OBJETIVO: Analisar a evolucao da mortalidade, por idade e sexo, segundo as causas de morte, nas regioes metropolitanas de Belo Horizonte (RMBH) e Salvador (RMS), entre 1985 e 1995. METODOS: Os dados utilizados foram provenientes do Registro Civil, fornecidos pelo SIM (Sistema de Informacao sobre Mortalidade do Ministerio da Saude). As causas de morte foram classificadas em evitaveis e nao evitaveis. Aplicou-se o metodo de decomposicao de Pollard para analisar a contribuicao, na evolucao dos ganhos de esperanca de vida ao nascer, dos grupos de causas que tiveram um aumento da sua participacao relativa na estrutura da mortalidade. RESULTADOS: O processo de declinio da mortalidade, em curso nas regioes metropolitanas estudadas, vem sofrendo mudancas nas ultimas decadas com uma tendencia a reducao dos diferenciais existentes. No seu conjunto, as causas evitaveis reduziram seu peso relativo em ambas as regioes: na RMBH, de 36,5%, em 1985, para 30,6%, em 1995, entre os homens, e de 34,9%, em 1985, para 28%, em 1995, entre as mulheres. Na RMS, observou-se uma reducao maior da participacao relativa para as mulheres: de 35,4%, em 1985, para 25,9%, em 1995. Para os homens, essa participacao passou de 44% do total, em 1985, para 39,7%, em 1995. CONCLUSOES: Ainda persiste uma estrutura de causas de morte que pode estar indicando que, nas regioes estudadas, os progressos nos niveis de mortalidade nao estao atingindo as populacoes menos favorecidas na intensidade e velocidade esperadas.OBJECTIVE To analyze differential changes of rates and stratification of mortality by gender and causes of death in the metropolitan area of Belo Horizonte (RMBH) and Salvador (RMS) between 1985 and 1995. METHODS The Ministry of Healths Mortality Information System (SIM) provides data on death causes by age and sex that was used for this study. The groups of death causes were classified according to two major groups (preventable and non-preventable) and the decomposition method presented by Pollard was applied to analyze the contribution of each group of death causes in the changes in life expectation. RESULTS There have been changes in the pace of the current mortality rate decline in RMBH and RMS, which have resulted in a reduction in the differences between the mortality rates in both areas. In both areas there was a substantial reduction in the mortality rates in the group of preventable causes, especially among women. CONCLUSIONS There is still a structure of death causes, which seems to indicate that the improvement in mortality among the poor has been lower than it was expected.

Morbidade hospitalar por doença de Chagas no Brasil

A pesquisa objetivou caracterizar a distribuicao e evolucao do numero de pacientes internados por doenca de Chagas no Brasil na ultima decada. Procurou tambem discutir os limites e possibilidades da Autorizacao de Internacao Hospitalar(AIH) na informacao epidemiologica. Constatou-se que em numeros absolutos e relativos, as internacoes por tripanosomiase sao pouco significativas dada a magnitude da doenca no pais. A maior parte das hospitalizacoes com este diagnostico ocorreu em Sao Paulo (com quase metade dos pacientes internados no pais), Minas Gerais, Goias e Distrito Federal. Quanto a natureza do hospital, verificou-se um aumento da importância do setor publico e uma grande participacao dos hospitais universitarios nas internacoes por esta causa. Em termos de despesas com estas hospitalizacoes, observa-se que a hegemonia do Estado de Sao Paulo e reforcada e que o custo medio e muito variado de acordo com a localizacao e a natureza do hospital. O trabalho concluiu que a utilizacao mais apropriada da fonte AIH seria no estudo de doencas que nao apresentam uma gama muito variada deformas clinicas, sendo suficientes as informacoes disponiveis no banco de dados SINTESE.

Comparison of crude and adjusted mortality rates from leading causes of death in northeastern Brazil

OBJECTIVE To present how the adjustment of incompleteness and misclassification of causes of death in the vital registration (VR) system can contribute to more accurate estimates of the risk of mortality from leading causes of death in northeastern Brazil. METHODS After estimating the total numbers of deaths by age and sex in Brazils Northeast region in 2002-2004 by correcting for undercount in the VR data, adjustment algorithms were applied to the reported cause-of-death structure. Average annual age-standardized mortality rates were computed by cause, with and without the corrections, and compared to death rates for Brazils South region after adjustments for potential misdiagnosis. RESULTS Death rates from ischemic heart disease, lower respiratory infections, chronic obstructive pulmonary disease, and perinatal conditions were more than 100% higher for both sexes than what was suggested by the routine VR data. Corrected cause-specific mortality rates were higher in the Northeast region versus the South region for the majority of causes of death, including several noncommunicable conditions. CONCLUSIONS Failure to adjust VR data for undercount of cases reported and misdiagnoses will cause underestimation of mortality risks for the populations of the Northeast region, which are more vulnerable than those in other regions of the country. In order to more reliably understand the pattern of disease, all cause-specific mortality rates in poor populations should be adjusted.

A evolução da mortalidade por causas mal definidas na população idosa em quatro capitais brasileiras, 1996-2007

The objective of this article is to study the evolution of mortality from ill-defined causes in the population over age 60 in the Brazilian cities of Belo Horizonte, Rio de Janeiro, Sao Paulo and Porto Alegre between 1996 and 2007. The evolution of the proportion of deaths due to ill-defined causes during this period was analyzed, as well as the distribution of these deaths by age group, according to the codes in Chapter XVIII of the International Disease Classification (IDC-10) and the position of this group of causes in the total number of deaths of elderly persons. The chance ratio (95%) for ill-defined causes and their occurrence in hospitals was also evaluated. The evolution of the proportion of deaths from ill-defined causes between 1996 and 2007 in the cities mentioned indicated that the highest proportion of deaths from ill-defined causes in the elderly was in Rio de Janeiro, where such deaths are in 4th place among all causes for this age group. In addition, the percentage of deaths from ill-defined causes that occurred in hospitals in Rio de Janeiro was almost twice as high as that in the other cities. As expected, the classification of cause of death as ill-defined was negatively associated with deaths that occurred in hospitals. The findings show good quality of information but indicate frequent problems in providing medical attention to the elderly population.

Investigation of ill-defined causes of death: assessment of a program's performance in a State from the Northeastern region of Brazil

OBJECTIVE The proportion of ill-defined causes of death (IDCD) was persistently high in some regions of Brazil in 2004. In 2005, the Brazilian government implemented a project in order to decrease this proportion, especially in higher priority states and municipalities. This study aimed to evaluate the performance of this project in Alagoas - a state from the Northeast region of Brazil. METHOD We selected a probabilistic sample of 18 municipalities. For all IDCD identified in 2010, we collected the verbal autopsy (VA) questionnaires used for home investigation, and the Ministry of Health (MoH) form, which contains information about the final disease and cause of death taken from hospital records, autopsies, family health teams, and civil registry office records. The completion rate of the MoH form and VA was calculated using the number of deaths with specific causes assigned among investigated deaths. RESULTS A total of 681 IDCD were recorded in 2010 in the sample, of which 26% had a MoH and/or VA3 forms completed. Although the majority of cases were attended by health professionals during the terminal disease, the completion rate was 45% using the MoH form and 80% when VA was performed. CONCLUSIONS Our findings provide evidence that the training of the epidemiological surveillance teams in the investigation and certification of causes of death could contribute to improve the quality of mortality data.

Mudanças curriculares: principais dificuldades na Implementação do PROMED

This study aims to discuss the difficulties faced by medical schools in the implementation of curricular changes, within the context of the Incentive Program for Curricular Changes for Medical Schools - PROMED. Interviews were conducted with heads of medicine courses and local SUS managers, as well as focus groups with students and teachers. The main limiting factors are related to teachers, students, educational institutions, SUS services/management and the conditions established in the PROMED Rules. Regarding the teachers, there was resistance to the proposed changes, insufficient teacher training and lack of knowledge about the Pedagogical Project of their own institution. Among students, the main barriers were related to practice in Primary Health Care settings and to restrictions regarding the training of physicians of a generalist profile. The conditions inadequacy of the Basic Health Units, as a teaching scenario, was the main difficulty related to services/management. The study shows the diversity and complexity of the obstacles faced by medical schools in implementing their projects for curricular change. This requires joint efforts of actors and institutions involved in the realization of the proposed change.