Maria Stella de Castro Lobo

Financing reform and productivity change in Brazilian teaching hospitals: Malmquist approach

This study evaluates the performance and productivity changes for the Brazilian Federal University Hospitals, considering the years of 2003 and 2006, that is, before and after a 2004 financing reform. The analysis is based on the Malmquist index approach. Results indicate that the financing reform provided improvement in the technical efficiency, although the technological frontier has not presented a positive shift. This suggests that increased budgets were a good stimulus for efficiency but the intended enhancement of the technology through the financing reform has not yet taken place.

O uso da Análise Envoltória de Dados (DEA) para avaliação de hospitais universitários brasileiros

In order to demonstrate how DEA modeling can be helpful for hospital performance assessments conducted in compliance with Brazils Teaching Hospital Policy, a case study is presented of 31 general hospitals linked to Federal Universities. It considers data on assistance, teaching and research and the use of the IDEAL (Interactive Data Envelopment Analysis Laboratory) software as a tool for assessing their efficiency. Developed in Brazil, this unique software provides a three-dimensional view of the productivity frontier, for easier exploratory analyses and selection of pertinent variables, with a better understanding of the outputs of the model (multiplier and envelope) for specialists and decision-makers. As an example, a University Hospital benchmark is presented through outputs that take structural and regional input differences into consideration. This modeling also indicates the changes required in the inefficient units (alterations to input and/or /output vectors), setting forth recommendations on public financing based on quality/efficiency.

Evaluating the performance of Brazilian university hospitals

In order to demonstrate how DEA modeling can be helpful to aid decision making relative to the Brazilian Teaching Hospital Policy by means of hospital performance assessment, we develop a case study with 30 general hospitals linked to Brazilian Federal Universities. We consider data on medical care (Medical Model—MM), teaching and research (Teaching-Research Model—TRM) and use the software IDEAL (Interactive Data Envelopment Analysis Laboratory) as a tool for the units’ efficiency evaluation. IDEAL, developed in Brazil, is unique in providing a 3-D frontiers visualization, assisting in exploratory analysis and allowing a better understanding of the DEA modeling (envelopment and multiplier). Both models are input-oriented and each hospital is categorized according to its relative efficiency in the MM and TRM. In this phase, it is very important to discuss with the decision-makers the results and patterns of the DEA models. Finally, the modelling indicates the necessary changes for the inefficient units and generates recommendations for teaching ratios and public financing.

Clinical and diagnostic aspects of intestinal microsporidiosis in HIV-infected patients with chronic diarrhea in Rio de Janeiro, Brazil

The objectives of this study were to determine both the prevalence of microsporidial intestinal infection and the clinical outcome of the disease in a cohort of 40 HIV-infected patients presenting with chronic diarrhea in Rio de Janeiro, Brazil. Each patient, after clinical evaluation, had stools and intestinal fragments examined for viral, bacterial and parasitic pathogens. Microsporidia were found in 11 patients (27.5%) either in stools or in duodenal or ileal biopsies. Microsporidial spores were found more frequently in stools than in biopsy fragments. Samples examined using transmission electron microscopy (n=3) or polymerase chain reaction (n=6) confirmed Enterocytozoon bieneusi as the causative agent. Microsporidia were the only potential enteric pathogens found in 5 of the 11 patients. Other pathogens were also detected in the intestinal tract of 21 patients, but diarrhea remained unexplained in 8. We concluded that microsporidial infection is frequently found in HIV infected persons in Rio de Janeiro, and it seems to be a marker of advanced stage of AIDS.

Pressão arterial, glicemia capilar e medidas antropométricas em uma população Yanomámi

Com o objetivo de avaliar o comportamento da glicemia capilar e das pressoes arteriais sistolica (PAS) e diastolica (PAD) em funcao de medidas antropometricas, foram examinados 72 Yanomami adultos na Area de Relacoes Intercomunitarias de Surucucus, Estado de Roraima. A pressao arterial foi mais elevada nos homens do que nas mulheres (PAS = 109,8 mm Hg e 100,2 mm Hg; PAD = 71,2 mm Hg e 63,5 mm Hg, respectivamente). Nao houve valores compativeis com a hipertensao arterial. A PAS correlacionou-se negativamente com a idade e positivamente com altura, peso, indice de massa corporal (IMC) e circunferencias abdominal e do quadril. O controle pelo IMC nao alterou a correlacao inversa entre PAS e idade. A correlacao da PAS com a altura inverteu-se quando controlada pelo peso, enquanto o controle pela altura nao alterou a correlacao positiva entre peso e PAS. A PAD correlacionou-se positivamente com o peso e a altura. A glicemia foi significativamente mais elevada nas mulheres do que nos homens (114,1 mg/dl e 98,4 mg/dl, respectivamente). Controlando-se pelo peso, a circunferencia abdominal correlacionou-se positivamente com a glicemia. Ao se controlar pela circunferencia abdominal, o peso e o IMC correlacionaram-se inversamente com a glicemia. Os achados sugerem que, enquanto a PAS correlaciona-se principalmente com a massa corporal, a glicemia capilar esta mais correlacionada com a concentracao abdominal de gordura.

Avaliação de desempenho e integração docente-assistencial nos hospitais universitários

OBJECTIVE To assess the performance and integration between the health care and teaching dimensions in Brazilian university hospitals. METHODS A network data envelopment analysis (DEA) model was designed to measure the performance of federal university hospitals, which enables the relationship between the teaching and health care dimensions to be considered simultaneously. Data from the Ministry of Education Information System of University Hospitals, in the second semester of 2003, were used. Results of the network model were compared to those of classical DEA models to assess the advantages of the new methodological proposal. RESULTS The efficiency of the hospitals assessed varied between 0.19 and 1.00 (mean = 0.54). The dimensional score showed that hospitals prioritize the gain in health care efficiency. It was observed that there was a need to double the number of medical students and increase the number of residents by 14% to obtain efficiency in the teaching dimension. CONCLUSIONS The model was useful for both unit managers, aiming to integrate teaching and health care, and regulatory organizations, when defining policies and incentives.OBJETIVO: Avaliar o desempenho e a integracao entre as dimensoes de assistencia e de ensino dos hospitais universitarios brasileiros. METODOS: Um modelo de data envelopment analysis em redes (network DEA) foi elaborado para aferir o desempenho de hospitais universitarios federais, o qual permite considerar a relacao entre as dimensoes de ensino e de assistencia, simultaneamente. Foram utilizados os dados do Sistema de Informacao dos Hospitais Universitarios do Ministerio da Educacao, referentes ao segundo semestre de 2003, e os resultados do modelo network foram comparados aqueles dos modelos DEA tradicionais para avaliacao das vantagens da nova proposta metodologica. RESULTADOS: A eficiencia dos hospitais avaliados variou entre 0,19 e 1,00 (media = 0,54). O escore dimensional mostrou que os hospitais priorizam o ganho de eficiencia assistencial. Observou-se que ha necessidade de dobrar o numero de alunos de medicina e de aumentar os residentes em 14% para que se tornem eficientes na dimensao de ensino. CONCLUSOES: O modelo mostrou utilidade de aplicacao tanto para os gestores das unidades, visando a integracao docente-assistencial, como para os orgaos reguladores, na definicao de politicas e incentivos.

Teaching hospitals in Brazil: Findings on determinants for efficiency

Abstract Hospital efficiency is an important dimension for health services evaluation and suffers the influence of different non-discretionary variables, not necessarily under the control of the hospital manager. These must be considered when establishing goals for efficient and socially committed health, which in many countries is now the primary goal. To test and further understand the context of non-controllable variables in healthcare delivery, this study examined 104 teaching hospitals in Brazil. The efficiency score was generated using weight restricted-output oriented data envelopment analysis model. A second-stage logistic regression analysis was deployed to examine the predictors of efficiency among the non-discretionary variables. The efficiency results indicate that, it requires reduction in labor and in bed capacity, while it increases necessary admissions and high complexity procedures. The main predictors of efficiency were the size of the hospital, high teaching intensity, and low teaching dedication. The model predicts no association between efficiency and ownership. Teaching load, as an important source of qualified human resources to society, although associated with higher health costs, when not considered in service delivery, may distort the analysis of efficiency for the teaching hospitals. These findings could have implications for any healthcare system that has teaching hospitals among its components.

Assessment of teaching-health care integration and performance in university hospitals

OBJECTIVE To assess the performance and integration between the health care and teaching dimensions in Brazilian university hospitals. METHODS A network data envelopment analysis (DEA) model was designed to measure the performance of federal university hospitals, which enables the relationship between the teaching and health care dimensions to be considered simultaneously. Data from the Ministry of Education Information System of University Hospitals, in the second semester of 2003, were used. Results of the network model were compared to those of classical DEA models to assess the advantages of the new methodological proposal. RESULTS The efficiency of the hospitals assessed varied between 0.19 and 1.00 (mean = 0.54). The dimensional score showed that hospitals prioritize the gain in health care efficiency. It was observed that there was a need to double the number of medical students and increase the number of residents by 14% to obtain efficiency in the teaching dimension. CONCLUSIONS The model was useful for both unit managers, aiming to integrate teaching and health care, and regulatory organizations, when defining policies and incentives.OBJETIVO: Avaliar o desempenho e a integracao entre as dimensoes de assistencia e de ensino dos hospitais universitarios brasileiros. METODOS: Um modelo de data envelopment analysis em redes (network DEA) foi elaborado para aferir o desempenho de hospitais universitarios federais, o qual permite considerar a relacao entre as dimensoes de ensino e de assistencia, simultaneamente. Foram utilizados os dados do Sistema de Informacao dos Hospitais Universitarios do Ministerio da Educacao, referentes ao segundo semestre de 2003, e os resultados do modelo network foram comparados aqueles dos modelos DEA tradicionais para avaliacao das vantagens da nova proposta metodologica. RESULTADOS: A eficiencia dos hospitais avaliados variou entre 0,19 e 1,00 (media = 0,54). O escore dimensional mostrou que os hospitais priorizam o ganho de eficiencia assistencial. Observou-se que ha necessidade de dobrar o numero de alunos de medicina e de aumentar os residentes em 14% para que se tornem eficientes na dimensao de ensino. CONCLUSOES: O modelo mostrou utilidade de aplicacao tanto para os gestores das unidades, visando a integracao docente-assistencial, como para os orgaos reguladores, na definicao de politicas e incentivos.

Difficulties in access and estimates of public beds in intensive care units in the state of Rio de Janeiro

ABSTRACT OBJECTIVE To estimate the required number of public beds for adults in intensive care units in the state of Rio de Janeiro to meet the existing demand and compare results with recommendations by the Brazilian Ministry of Health. METHODS The study uses a hybrid model combining time series and queuing theory to predict the demand and estimate the number of required beds. Four patient flow scenarios were considered according to bed requests, percentage of abandonments and average length of stay in intensive care unit beds. The results were plotted against Ministry of Health parameters. Data were obtained from the State Regulation Center from 2010 to 2011. RESULTS There were 33,101 medical requests for 268 regulated intensive care unit beds in Rio de Janeiro. With an average length of stay in regulated ICUs of 11.3 days, there would be a need for 595 active beds to ensure system stability and 628 beds to ensure a maximum waiting time of six hours. Deducting current abandonment rates due to clinical improvement (25.8%), these figures fall to 441 and 417. With an average length of stay of 6.5 days, the number of required beds would be 342 and 366, respectively; deducting abandonment rates, 254 and 275. The Brazilian Ministry of Health establishes a parameter of 118 to 353 beds. Although the number of regulated beds is within the recommended range, an increase in beds of 122.0% is required to guarantee system stability and of 134.0% for a maximum waiting time of six hours. CONCLUSIONS Adequate bed estimation must consider reasons for limited timely access and patient flow management in a scenario that associates prioritization of requests with the lowest average length of stay.

Dynamic network data envelopment analysis for university hospitals evaluation

ABSTRACT OBJECTIVE To develop an assessment tool to evaluate the efficiency of federal university general hospitals. METHODS Data envelopment analysis, a linear programming technique, creates a best practice frontier by comparing observed production given the amount of resources used. The model is output-oriented and considers variable returns to scale. Network data envelopment analysis considers link variables belonging to more than one dimension (in the model, medical residents, adjusted admissions, and research projects). Dynamic network data envelopment analysis uses carry-over variables (in the model, financing budget) to analyze frontier shift in subsequent years. Data were gathered from the information system of the Brazilian Ministry of Education (MEC), 2010-2013. RESULTS The mean scores for health care, teaching and research over the period were 58.0%, 86.0%, and 61.0%, respectively. In 2012, the best performance year, for all units to reach the frontier it would be necessary to have a mean increase of 65.0% in outpatient visits; 34.0% in admissions; 12.0% in undergraduate students; 13.0% in multi-professional residents; 48.0% in graduate students; 7.0% in research projects; besides a decrease of 9.0% in medical residents. In the same year, an increase of 0.9% in financing budget would be necessary to improve the care output frontier. In the dynamic evaluation, there was progress in teaching efficiency, oscillation in medical care and no variation in research. CONCLUSIONS The proposed model generates public health planning and programming parameters by estimating efficiency scores and making projections to reach the best practice frontier.