Mariangela Leal Cherchiglia

Avaliação da qualidade dos serviços de saúde: notas bibliográficas

No momento em que se discute a reorganizacao dos servicos de saude no Brasil, a avaliacao da qualidade destes servicos ganha importância. Nesta revisao, buscamos os antecedentes historicos da avaliacao dos servicos de saude e apresentamos as propostas contemporâneas de sistematizacao da avaliacao de qualidade. Atraves da analise dos trabalhos revisados, identificamos duas grandes linhas metodologicas de acordo com seu objeto de estudo: Estudos Corporativos Racionalizadores e Estudos Antropossociais. A maioria destes se referenciam nos trabalhos desenvolvidos por Avedis Donabedian, autor que, nos ultimos vinte anos, vem desenvolvendo estudos de avaliacao dos servicos de saude.

Perfil epidemiológico dos pacientes em terapia renal substitutiva no Brasil, 2000-2004

OBJECTIVE To describe the clinical and epidemiological profile of patients under renal replacement therapies, identifying risk factors for death. METHODS This is a non-concurrent cohort study of data for 90,356 patients in the National Renal Replacement Therapies Database. A deterministic-probabilistic linkage was performed using the Authorization System for High Complexity/Cost Procedures and the Mortality Information System databases. All patients who started dialysis between 1/1/2000 and 12/31/2004 were included and followed until death or the end of 2004. Age, sex, region of residence, primary renal disease and causes of death were analyzed. A proportional hazards model was used to identify factors associated with risk of death. RESULTS The prevalence of patients under renal replacement therapies increased an average of 5.5%, while incidence remained stable during the period. Hemodialysis was the predominant initial modality (89%). The patients were majority male with mean age 53 years, residents of the Southeast region and presented unknown causes as the main cause of chronic renal disease, followed by hypertension, diabetes and glomerulonephritis. Of these patients, 42% progressed to death and 7% underwent kidney transplantation. The patients on peritoneal dialysis were older and had higher prevalence of diabetes. The death rate varied from 7% among transplanted patients to 45% among non-transplanted patients. In the final Cox proportional hazards model, the risk of mortality was associated with increasing age, female sex, having diabetes, living in the North and Northeast region, peritoneal dialysis as a first modality and not having renal transplantation. CONCLUSIONS There was an increased prevalence of patients on renal therapy in Brazil. Increased risk of death was associated with advanced age, diabetes, the female sex, residents of the North and Northeast region and lack of renal transplant.OBJETIVO: Describir el perfil epidemiologico y clinico de pacientes en terapia renal substitutiva, identificando factores asociados al riesgo de muerte. METODOS: Estudio de observacion, prospectivo no concurrente, a partir de datos de 90.356 pacientes de la Base Nacional en Terapias Renales Substitutivas, en Brasil. Fue realizado reracionamiento deterministico-probabilistico del Sistema de Informacion de Mortalidad. Fueron incluidos todos los pacientes incidentes que iniciaron dialisis entre 1/1/2000 y 31/12/2004, acompanados hasta la muerte o final de 2004. Edad, sexo, region de residencia, enfermedad renal primaria, causa del obito fueron analizados. Se ajusto un modelo de riesgos proporcionales para identificar factores asociados al riesgo de muerte. RESULTADOS: Ocurrio un aumento promedio de 5,5% en la prevalencia de pacientes en terapia, con relacion a la incidencia se mantuvo estable en el periodo. Hemodialisis fue la modalidad inicial predominante (89%). La mayoria de los pacientes era del sexo masculino, con edad promedio de 53 anos, residente en la region Sureste y presentaba causa indeterminada como principal causa basica de la enfermedad renal cronica, seguida de la hipertension, diabetes y glomerulonefritis. De esos pacientes, 7% realizaron transplante renal y 42% evolucionaron a obito. Los pacientes en dialisis peritoneal eran mas ancianos y presentaban mayor prevalencia de diabetes. Entre los no transplantados, 45% fueron a obito y, entre los transplantadas 7%. En el modelo final de riesgos proporcionales de Cox, el riesgo de mortalidad estuvo asociado con el aumento de la edad, sexo femenino, tener diabetes, residir en la region Norte y Noreste, dialisis peritoneal como modalidad de entrada y no haber realizado transplante renal. CONCLUSIONES: Hubo aumento de la prevalencia de pacientes en terapia renal en Brasil. Pacientes con edad avanzada, diabetes, del sexo femenino, residentes en la region Norte y Noreste y sin transplante renal presentan mayor riesgo de muerte.

Quality of life of patients in renal replacement therapy in Brazil: comparison of treatment modalities

PurposeThis study aimed to analyze and compare the quality of life of renal replacement therapy patients undergoing hemodialysis, peritoneal dialysis and those with renal transplantation in Brazil. In addition, we aimed to verify factors associated with patients’ quality of life and the relationship between quality of life and treatment modality, socioeconomic and demographic conditions as well as aspects related to the disease and health services.MethodsA representative sample of the dialysis units and transplant centers was obtained. Structured questionnaires were used to interview 3,036 patients in one of three treatment modalities: hemodialysis, peritoneal dialysis and renal transplant. Information was collected about socioeconomic and demographic characteristics and quality of life measures.ResultsThere were significant differences between renal transplants and both forms of dialysis for all dimensions of the SF-36. Hemodialysis patients showed better results in the dimensions of functional capacity, physical aspects and social aspects, compared to peritoneal dialysis patients. Renal transplant patients had the best mean score in the physical component of quality of life. There were no significant differences among treatment groups regarding the mental component of quality of life. The physical and mental components were associated with comorbidities and age; however, older patients had better mental quality of life but worse physical quality of life. Patients in a higher socioeconomic class and patients that were not hospitalized also reported better quality of life. Unmarried and male patients presented better physical quality of life. The dialysis units and transplant centers influenced the patients’ quality of life.ConclusionsRenal transplant patients have the best quality of life of the three treatment modalities. It is necessary to increase access to renal transplants.

Acesso aos procedimentos de media e alta complexidade no Sistema Unico de Saude: uma questao de judicializacao

Lawsuits in healthcare have increased exponentially in Brazil. However, the judicialization of healthcare procedures has not been sufficiently discussed, although such a discussion could broaden the scope of healthcare assessment. This study aimed to analyze the use of court action to ensure access to outpatient and hospital procedures from 1999 to 2009 in the State of Minas Gerais, Brazil. This was a retrospective descriptive study. Procedures were classified according to the Brazilian Unified National Health System (SUS) and the Table on Unified Terminology for Private Healthcare. Coverage by the SUS was 93.5%. The largest proportions of beneficiaries of such lawsuits lived in the Central and Western regions of the country (26.4% and 24%, respectively). The most common procedures involved in such cases were clinical admissions, admission to intensive care, and cardiovascular surgery. The study highlights the emerging need for access to medium and high-complexity procedures through extensive rules for coverage.Os processos judiciais na area da saude tem crescido de forma exponencial. A judicializacao de procedimentos, no entanto, ainda nao foi discutida e pode ampliar o escopo de avaliacao da atencao a saude. O objetivo deste estudo e investigar as acoes judiciais para acesso a procedimentos ambulatoriais e hospitalares do Estado de Minas Gerais, Brasil, no periodo de 1999 a 2009. E um estudo descritivo retrospectivo. Os procedimentos foram classificados pela Tabela Unificada do SUS e pela Tabela de Terminologia Unificada da Saude Suplementar. Observou-se cobertura pelo SUS de 93,6%. A residencia dos beneficiarios localiza-se, principalmente, nas macrorregioes Centro (26,4%) e Oeste (24%). Os procedimentos mais solicitados foram internacoes em leitos comuns, Centro de Terapia Intensiva e cirurgias do aparelho circulatorio. Este estudo aponta para as necessidades emergentes de acesso aos procedimentos de media e alta complexidade, mediante uma extensa cobertura normativa.

Determinants of expenditures on dialysis in the Unified National Health System, Brazil, 2000 to 2004

The aim of this study was to compare total outpatient expenditures on hemodialysis and peritoneal dialysis from 2000 to 2004 in patients that began dialysis in 2000 under the Unified National Health System (SUS). A historical cohort was developed, consisting of patients that began dialysis in 2000, identified by probabilistic matching in the database of Authorizations for High-Complexity/High-Cost Procedures (APAC). A multiple linear regression model was used, including individual and clinical attributes and health services supply variables. The cohort included 10,899 patients, 88.5% of whom began hemodialysis and 11.5% peritoneal dialysis. The dialysis modality explains 12% of the variance in expenditures, and patients in peritoneal dialysis showed 20% higher mean annual expenditure. The differences in expenditures are explained according to the State of Brazil and health services supply level. Individual risk variables did not alter the models explanatory power, while age and diabetes mellitus were significant. The study showed the importance of the National Health Systems payment mechanism for explaining differences in expenditures on dialysis treatment in Brazil.

Pesquisa e produção científica em economia da saúde no Brasil

This article presents a diagnosis of the health economics (HE) in Brazil, based on a survey of HE research groups currently registered in the National Council for Scientific and Technological Development (CNPq), as well as an inventory of the Brazilian scientific production in HE, published between January 1999 and June 2004, available in the Bireme Virtual Health Library (Paho/WHO). It describes the data considering geographic regions, types of institution and topics of research. Of the research groups with works related to HE subject matters, 48 have very diversified activities, concentrated in the Southeastern region of the country. Only 14% (376) of the 2.617 publications that had been evaluated were related to HE. Most of the studies were published in 2002 and their main topics were management, financing, allocative efficiency and equity in the distribution of health resources. The diagnosis allows the identification of important aspects that help understand the development of the HE field in Brazil between 1999 and 2004.

O Sistema de Vigilância Alimentar e Nutricional como instrumento de monitoramento da Estratégia Nacional para Alimentação Complementar Saudável

OBJECTIVES: to examine the Food and Nutrition Surveillance System (Sisvan) as a tool for monitoring the National Strategy for Healthy Complementary Nutrition (ENPACS) in the 40 municipalities overseen by the Belo Horizonte regional superintendent for health (SRS-BH). METHODS: a descriptive study was carried out involving all children aged under two being accompanied by the Sisvan Web between 2008 and 2011. The coverage of the Sisvan Web was calculated by dividing the number of children aged under two years accompanied by the Sisvan Web by the total population for the same age group. A questionnaire relating to the technical references of the Sisvan of the municipalities under investigation was sent to collect information on the functioning of the Sisvan. RESULTS: the coverage of the Sisvan Web, in all municipalities, varied from 4.3% (2008) to 10.7% (2011). The questionnaire was answered by 38 municipalities in the SRS-BH, 31.6% of whom reported using data from the Sisvan Web system as a basis for nutritional interventions. CONCLUSIONS: the study identified low coverage, poor utilization of data and the need to improve the Sisvan, in order to generate consistent information on nutrition and food among children aged under two years, thereby making it appropriate for monitoring of the ENPACS.

Epidemiological profile of patients on renal replacement therapy in Brazil, 2000-2004.

OBJECTIVE To describe the clinical and epidemiological profile of patients under renal replacement therapies, identifying risk factors for death. METHODS This is a non-concurrent cohort study of data for 90,356 patients in the National Renal Replacement Therapies Database. A deterministic-probabilistic linkage was performed using the Authorization System for High Complexity/Cost Procedures and the Mortality Information System databases. All patients who started dialysis between 1/1/2000 and 12/31/2004 were included and followed until death or the end of 2004. Age, sex, region of residence, primary renal disease and causes of death were analyzed. A proportional hazards model was used to identify factors associated with risk of death. RESULTS The prevalence of patients under renal replacement therapies increased an average of 5.5%, while incidence remained stable during the period. Hemodialysis was the predominant initial modality (89%). The patients were majority male with mean age 53 years, residents of the Southeast region and presented unknown causes as the main cause of chronic renal disease, followed by hypertension, diabetes and glomerulonephritis. Of these patients, 42% progressed to death and 7% underwent kidney transplantation. The patients on peritoneal dialysis were older and had higher prevalence of diabetes. The death rate varied from 7% among transplanted patients to 45% among non-transplanted patients. In the final Cox proportional hazards model, the risk of mortality was associated with increasing age, female sex, having diabetes, living in the North and Northeast region, peritoneal dialysis as a first modality and not having renal transplantation. CONCLUSIONS There was an increased prevalence of patients on renal therapy in Brazil. Increased risk of death was associated with advanced age, diabetes, the female sex, residents of the North and Northeast region and lack of renal transplant.OBJETIVO: Describir el perfil epidemiologico y clinico de pacientes en terapia renal substitutiva, identificando factores asociados al riesgo de muerte. METODOS: Estudio de observacion, prospectivo no concurrente, a partir de datos de 90.356 pacientes de la Base Nacional en Terapias Renales Substitutivas, en Brasil. Fue realizado reracionamiento deterministico-probabilistico del Sistema de Informacion de Mortalidad. Fueron incluidos todos los pacientes incidentes que iniciaron dialisis entre 1/1/2000 y 31/12/2004, acompanados hasta la muerte o final de 2004. Edad, sexo, region de residencia, enfermedad renal primaria, causa del obito fueron analizados. Se ajusto un modelo de riesgos proporcionales para identificar factores asociados al riesgo de muerte. RESULTADOS: Ocurrio un aumento promedio de 5,5% en la prevalencia de pacientes en terapia, con relacion a la incidencia se mantuvo estable en el periodo. Hemodialisis fue la modalidad inicial predominante (89%). La mayoria de los pacientes era del sexo masculino, con edad promedio de 53 anos, residente en la region Sureste y presentaba causa indeterminada como principal causa basica de la enfermedad renal cronica, seguida de la hipertension, diabetes y glomerulonefritis. De esos pacientes, 7% realizaron transplante renal y 42% evolucionaron a obito. Los pacientes en dialisis peritoneal eran mas ancianos y presentaban mayor prevalencia de diabetes. Entre los no transplantados, 45% fueron a obito y, entre los transplantadas 7%. En el modelo final de riesgos proporcionales de Cox, el riesgo de mortalidad estuvo asociado con el aumento de la edad, sexo femenino, tener diabetes, residir en la region Norte y Noreste, dialisis peritoneal como modalidad de entrada y no haber realizado transplante renal. CONCLUSIONES: Hubo aumento de la prevalencia de pacientes en terapia renal en Brasil. Pacientes con edad avanzada, diabetes, del sexo femenino, residentes en la region Norte y Noreste y sin transplante renal presentan mayor riesgo de muerte.

Quality of life of patients with Diabetes Mellitus Types 1 and 2 from a referal health centre in Minas Gerais, Brazil

ABSTRACT Quality of life (QoL) characteristics are important in patients with diabetes mellitus (DM 1 and 2). Aim: Evaluate QoL and DM-associated factors among diabetic patients. Methods: Patients attending a University Hospital were interviewed about their sociodemographic, clinical and QoL characteristics, with QoL measured via the EQ-5D. Descriptive analysis, correlation, linear regression, univariate and multivariate analysis were performed. Results: 346 patients took part, comprising 67% women, 59% with DM2, and 32% DM1. DM 1 patients had a mean QoL score of 0.7369, with retinopathy, depression, dyslipidemia and a serious hypoglycemic crisis significantly reducing QoL. Patients with DM type 2 had a mean QoL score of 0.6582, with hypertension, neuropathy, depression, cancer and dyslipidemia significantly reducing QoL. Reduced QoL also correlated with a lack of physical exercise. Males with both DM1 and 2 had a better QoL than females. Conclusion: Need for better disease monitoring and control combined with effective activities to improve self-care, reduce complications and improve patients’ QoL.

Perfil de utilização de medicamentos por indivíduos com hipertensão arterial e diabetes mellitus em municípios da Rede Farmácia de Minas

This article analyzes the use of medicines by individuals with hypertension and/or diabetes mellitus who received their medication through a public network of pharmacies, with a particular emphasis on gender differences. During the first two months of 2010, individuals with hypertension and/or diabetes were interviewed in half of the 64 municipalities (counties) participating in the Minas Gerais Pharmacy Network. Mean age of the 4,777 interviewees was 60.9 years, which may have contributed to the high mean number of medicines used (4.0 among women and 3.5 among men). The most frequently used drugs were those acting on the cardiovascular system (56.3%), alimentary tract and metabolism (14.9%), and nervous system (13.8%), consistent with the samples epidemiological profile. Women and more elderly individuals tended to use more medicines. The findings show high expenditures on medicines by the interviewees and suggest the design of educational activities targeting rational use of medication.