José Carvalho de Noronha

A política de saúde no Brasil nos anos 90

Os autores realizam uma reflexao sobre os rumos da reforma do setor saude na decada de 1990. Enfatizam a dinâmica de mudancas conjunturais e estruturais que, ao estigmatizar o sentido do Estado de Bem-Estar Social, acaba por minar as bases solidarias do projeto de seguridade social (no qual estava incluida a saude). Fazem tambem a critica ao modelo neoliberal que inclui, no seu interior, um pensamento privatista e focalizador sobre o setor saude, quando comparado ao modelo e aos principios do SUS. Mas ainda encontram varios elementos passiveis de serem articulados para revigorar o processo de construcao da Reforma Sanitaria que foi instituida na Constituicao de 1988.

Avaliação da relação entre volume de procedimentos e a qualidade do cuidado: o caso de cirurgia coronariana no Brasil

There is often a negative association between the volume of medical procedures and hospital mortality rates. The objective of this study is to determine whether this association is observed in Brazilian hospitals performing coronary artery bypass grafts (CABG) that were financed by the Ministry of Health. CABG surgeries performed from 1996 to 1998 were analyzed. Data were collected from the Ministry of Health Hospital Information System. The statistical procedure utilized was the Cox survival analysis. Hospitals were grouped in classes of volume of CABG performed. The model was adjusted to the severity of cases (risk of dying). From January 1996 to December 1998 the Ministry of Health reimbursed 41,989 CABG procedures in 131 hospitals. The overall hospital mortality rate was 7.2%. A gradient was observed in the mortality rates. The severity-adjusted risk of dying in the group of hospitals performing more procedures was lower than in the group performing fewer operations. It is recommended that the Ministry of Health strongly consider regionalized concentration of services to perform CABG.

Sistema de Informações Hospitalares como ajuste de risco em índices de desempenho

OBJECTIVEnTo analyze the use of the Brazilian Hospital Database (SIH/SUS) on risk adjustment of hospital mortality, and to evaluate the usefulness of the Charlson comorbidity index (CCI) for risk adjustment of indicators calculated with the available data from the SIH/SUS.nnnMETHODSnThe comorbidity index was applied on 40,299 patients admitted in hospital in Rio de Janeiro, Brazil. CCI determines specific values to 17 clinical conditions to measure the burden of the patients comorbidity, not taking into consideration the main diagnosis. Multiple logistic regression was applied to assess the impact of CCI in estimating the probability of dying.nnnRESULTSnCCI was greater than zero in only 5.7% admissions. When combined with age (combined CCI), the percentage of cases with a value greater than zero increased considerably. These models, however, showed to have a low sensitivity.nnnCONCLUSIONSnDespite comorbidity is an important predictor for the risk of dying, it was observed that this is not a good discriminatory variable of case severity in the studied database. This maybe due to incomplete diagnostic information in the database. In the SIH/SUS data, age is the most important predictor of the risk of dying. However, despite the limited quality of diagnostic information in SIH/SUS, the use of CCI combined with age for adjustment of the risk of dying is recommended in measures using this database.OBJETIVO: Analisar o uso do Sistema de Informacoes Hospitalares do Sistema Unico de Saude (SIH/SUS) no ajuste de risco das taxas de mortalidade hospitalar e avaliar a utilidade do indice de comorbidade de Charlson (ICC) no ajuste de risco de indicadores de desempenho. METODOS: Foram selecionadas 40.299 internacoes ocorridas no Municipio do Rio de Janeiro entre dezembro de 1994 e dezembro de 1996. A medida de gravidade foi testada pelo ICC, que atribui pesos a 17 condicoes clinicas presentes nos diagnosticos secundarios, a fim de obter a carga de morbidade do paciente (gravidade) independentemente do diagnostico principal. Utilizou-se a regressao logistica para avaliar o impacto do ICC na estimativa da chance de morrer no hospital. RESULTADOS: Nas internacoes selecionadas, observou-se que o ICC foi igual ou superior a um em apenas 5,7 % dos casos. Quando se aplicou o ICC combinado a idade, o percentual de casos com pontuacao diferente de zero aumentou substancialmente. Os modelos testados apresentaram reduzida sensibilidade. CONCLUSOES: Apesar de a presenca de comorbidade ser importante na predicao do risco de morrer, essa variavel pouco discriminou a gravidade dos casos na base de dados do SIH/SUS, o que e explicado pela qualidade da informacao diagnostica nessa base de dados, na qual a idade e o preditor mais importante do risco de morrer, afora o diagnostico principal. Apesar das limitacoes ainda existentes na qualidade da informacao diagnostica disponivel no SIH/SUS, sugere-se o uso do ICC combinado como medida para ajuste do risco de morrer nas taxas calculadas a partir desses dados.

Cobertura universal de saúde: como misturar conceitos, confundir objetivos, abandonar princípios

1, poderia ser mais um relatorio declaratorio, com um conjunto de boas intencoes, como muitos outros, nao fora o inte-resse alargado que a proposicao “cobertura uni-versal” despertou em circulos do pensamento conservador da saude, de defensores do “mer-cado” na prestacao de servicos, fundacoes que atuam na arena da Saude Global, como a Funda-cao Rockfeller, ate a prestigiosa revista inglesa de Medicina, oFollowing preliminary approval by the Commit-tee on the Environment and Consumer Defense, the Brazilian Senate is currently analyzing a bill of law with a pedagogical, political, and ethical scope and implications that could ensure it an important role in consolidating principles, stan-dards, and practical measures in the process of food and nutritional security for the Brazilian population. The bill places a ban on so-called “promotional tie-ins”, or the combined sales of food products with toys, an advertising device that specifically targets children. In other words, kids receive toys as “presents” or “prizes” with the purchase of certain food products, so that in their natural urge to play or have fun, their in-stinctive and physiological expression of hunger (appetite) is displaced by a marketing ploy: toys as gratifications or rewards, as souvenirs tied to the purchase of chocolate, candy, breakfast food, snacks, and soft drinks. Sometimes the food it-self is the toy or game, the point of departure or outcome of childhood fun, in which siblings, other children, and parents themselves play the role of bit actors in a game with a stacked deck. In other words, the winners and losers are known ahead of time. The winners are industry and commerce. The losers are the children and their families that agree to play the game.Yet this is only the most visible part of the problem. Dissimulated (or even more osten-sive) marketing ploys are pervasive: in the pack-ages’ appearance, on radio and TV, on the su-permarket shelves, in many schools’ snack bars and dining halls, and in the seemingly innocent games at kids’ clubs. In 2011, a PhD thesis

Violência: pobreza ou fraqueza institucional?

Os autores fazem uma revisao das estatisticas de mortalidade do Ministerio da Saude por causas externas no periodo de 1981 a 1989, para o qual encontram-se disponiveis dados nacionais. Examinam seu comportamento nas diferentes Unidades da Federacao, areas metropolitanas e capitais, com enfase nos obitos por homicidios. Confrontam esses dados com aqueles da distribuicao da pobreza no pais e dos fluxos migratorios. Concluem pela inexistencia de qualquer associacao entre as taxas de mortalidade por homicidios e pobreza ou migracao. Discutem que, se a associacao pode ser evidenciada nas contravencoes e nos crimes contra o patrimonio, nao ha qualquer sustentacao para sua associacao nos crimes contra a vida. Acentuam o papel do crime organizado, bem como do trafico de drogas e de armas, como fator predominante na estruturacao da criminalidade metropolitana, particularmente quando associado a uma politica exclusivamente repressiva de combate as drogas e a escolhas politicas e institucionais inadequadas para o enfrentamento da pobreza urbana.

Aplicação da mortalidade hospitalar após a realização de cirurgia de revascularização do miocárdio para monitoramento do cuidado hospitalar

Brazilian hospitals performing coronary artery by-pass graft surgery (CABG) from 1996 to 1998 and covered by the Ministry of Health were ranked according to their risk-adjusted hospital mortality rates. Seventy-six hospitals that performed more than 150 CABGs (total of 38,962 surgical interventions) were classified as low or high outliers according to the ratio between observed and expected hospital mortality rates. Overall hospital mortality rate was 7.20%. The rate was 3.48% among patients treated in the low outliers and 13.96% among the high outliers. The methodology was useful for discriminating Brazilian hospitals according to their post-CABG mortality rates and may be a useful tool for identifying hospitals with possible quality-of-care problems.Brazilian hospitals performing coronary artery by-pass graft surgery (CABG) from 1996 to 1998 and covered by the Ministry of Health were ranked according to their risk-adjusted hospital mortality rates. Seventy-six hospitals that performed more than 150 CABGs (total of 38,962 surgical interventions) were classified as low or high outliers according to the ratio between observed and expected hospital mortality rates. Overall hospital mortality rate was 7.20%. The rate was 3.48% among patients treated in the low outliers and 13.96% among the high outliers. The methodology was useful for discriminating Brazilian hospitals according to their post-CABG mortality rates and may be a useful tool for identifying hospitals with possible quality-of-care problems.

Universal health coverage: how to mix concepts, confuse objectives, and abandon principles

1, poderia ser mais um relatorio declaratorio, com um conjunto de boas intencoes, como muitos outros, nao fora o inte-resse alargado que a proposicao “cobertura uni-versal” despertou em circulos do pensamento conservador da saude, de defensores do “mer-cado” na prestacao de servicos, fundacoes que atuam na arena da Saude Global, como a Funda-cao Rockfeller, ate a prestigiosa revista inglesa de Medicina, oFollowing preliminary approval by the Commit-tee on the Environment and Consumer Defense, the Brazilian Senate is currently analyzing a bill of law with a pedagogical, political, and ethical scope and implications that could ensure it an important role in consolidating principles, stan-dards, and practical measures in the process of food and nutritional security for the Brazilian population. The bill places a ban on so-called “promotional tie-ins”, or the combined sales of food products with toys, an advertising device that specifically targets children. In other words, kids receive toys as “presents” or “prizes” with the purchase of certain food products, so that in their natural urge to play or have fun, their in-stinctive and physiological expression of hunger (appetite) is displaced by a marketing ploy: toys as gratifications or rewards, as souvenirs tied to the purchase of chocolate, candy, breakfast food, snacks, and soft drinks. Sometimes the food it-self is the toy or game, the point of departure or outcome of childhood fun, in which siblings, other children, and parents themselves play the role of bit actors in a game with a stacked deck. In other words, the winners and losers are known ahead of time. The winners are industry and commerce. The losers are the children and their families that agree to play the game.Yet this is only the most visible part of the problem. Dissimulated (or even more osten-sive) marketing ploys are pervasive: in the pack-ages’ appearance, on radio and TV, on the su-permarket shelves, in many schools’ snack bars and dining halls, and in the seemingly innocent games at kids’ clubs. In 2011, a PhD thesis

Quality Improvement Initiatives in Brazil: A Progress Report

BACKGROUNDnIn 1994 Brazils Ministry of Health (MOH) introduced a program to provide a supporting environment for quality improvement (QI) initiatives. Yet the five-track QI strategy, which included moving toward outcome indicators, establishing a national accreditation program, emphasizing QI tools, establishing basic clinical guidelines, and enhancing community control, was discontinued in 1998, following the dismissal of the minister of health. The QI program retained only its accreditation activities.nnnACCREDITATIONnThe Consortium for Brazilian Accreditation (CBA) began in 1994 to establish an accreditation process compatible with international initiatives. Both the MOH and the CBA have developed standards for hospitals. The Brazilian Manual for the Accreditation of Hospitals is available on the Internet. The CBA has developed a set of standards by adapting the 1996 hospital standards from the Joint Commission on Accreditation of Healthcare Organizations. To developing CBAs role as an accrediting organization, administrative and technical supporting structures were created within the Cesgranrio Foundation and a Joint Commission for Accreditation was established.nnnQUALITY MANAGEMENT INITIATIVESnA growing number of hospitals, clinical laboratories, blood banks, health plans, and other health care services and organizations are seeking International Organization for Standardization (Geneva) certification. Consulting firms in the field of quality management continue to increase the number of their clients in the health sector.nnnCONCLUDING REMARKSnCurrent QI initiatives represent only a minority of health care services and organizations in the country. Strong efforts need to be made by both the private and public sectors to expand such initiatives throughout Brazil.

Transformações de um ambulatório de medicina integral com vistas a um programa de atenção médica primária: a experiência do Hospital de Clínicas da Universidade do Estado do Rio de Janeiro, Brasil

Apos breve discussao de aspectos da assistencia medica ambulatorial, sao apresentadas as propostas de reorganizacao dos servicos ambulatoriais do Hospital de Clinicas da Universidade do Estado do Rio de Janeiro com vistas ao estabelecimento de um programa de medicina integral. Tambem sao apresentados os dados de uma pesquisa sobre padroes de utilizacao do ambulatorio. Alguns aspectos docentes do programa sao discutidos.

Cobertura universal de salud: cómo mezclar conceptos, confundir objetivos, abandonar princípios

1, poderia ser mais um relatorio declaratorio, com um conjunto de boas intencoes, como muitos outros, nao fora o inte-resse alargado que a proposicao “cobertura uni-versal” despertou em circulos do pensamento conservador da saude, de defensores do “mer-cado” na prestacao de servicos, fundacoes que atuam na arena da Saude Global, como a Funda-cao Rockfeller, ate a prestigiosa revista inglesa de Medicina, oFollowing preliminary approval by the Commit-tee on the Environment and Consumer Defense, the Brazilian Senate is currently analyzing a bill of law with a pedagogical, political, and ethical scope and implications that could ensure it an important role in consolidating principles, stan-dards, and practical measures in the process of food and nutritional security for the Brazilian population. The bill places a ban on so-called “promotional tie-ins”, or the combined sales of food products with toys, an advertising device that specifically targets children. In other words, kids receive toys as “presents” or “prizes” with the purchase of certain food products, so that in their natural urge to play or have fun, their in-stinctive and physiological expression of hunger (appetite) is displaced by a marketing ploy: toys as gratifications or rewards, as souvenirs tied to the purchase of chocolate, candy, breakfast food, snacks, and soft drinks. Sometimes the food it-self is the toy or game, the point of departure or outcome of childhood fun, in which siblings, other children, and parents themselves play the role of bit actors in a game with a stacked deck. In other words, the winners and losers are known ahead of time. The winners are industry and commerce. The losers are the children and their families that agree to play the game.Yet this is only the most visible part of the problem. Dissimulated (or even more osten-sive) marketing ploys are pervasive: in the pack-ages’ appearance, on radio and TV, on the su-permarket shelves, in many schools’ snack bars and dining halls, and in the seemingly innocent games at kids’ clubs. In 2011, a PhD thesis