Palmira de Fátima Bonolo

Internações por condições sensíveis à atenção primária: a construção da lista brasileira como ferramenta para medir o desempenho do sistema de saúde (Projeto ICSAP - Brasil)

Ambulatory care sensitive hospitalizations are a set of conditions for which access to effective primary care can reduce the likelihood of hospitalization. These hospitalizations have been used as an indicator of primary care performance in several countries and in three Brazilian states, but there is little consensus on which conditions should be included in this indicator. This paper presents a description of the steps undertaken to construct and validate a list for Brazil. The final list includes 20 groups of diagnostic conditions that represented 28.3% of a total of 2.8 million hospitalizations in the National Unified Health System in 2006. Gastroenteritis and complications, congestive heart failure, and asthma represented 44.1% of all ambulatory care sensitive hospitalizations. From 2000 to 2006, ambulatory care sensitive hospitalizations decreased by 15.8%, and this reduction was more significant than that observed in all other hospitalizations. The article concludes with potential applications and limitations of the proposed Brazilian list.

Major Expansion Of Primary Care In Brazil Linked To Decline In Unnecessary Hospitalization

In 1994 Brazil launched what has since become the worlds largest community-based primary health care program. Under the Family Health Program, teams consisting of at least one physician, one nurse, a medical assistant, and four to six trained community health agents deliver most of their services at community-based clinics. They also make regular home visits and conduct neighborhood health promotion activities. This study finds that during 1999-2007, hospitalizations in Brazil for ambulatory care-sensitive chronic diseases, including cardiovascular disease, stroke, and asthma, fell at a rate that was statistically significant and almost twice the rate of decline in hospitalizations for all other causes. In municipalities with high Family Health Program enrollment, chronic disease hospitalization rates were 13 percent lower than in municipalities with low enrollment, when other factors were held constant. These results suggest that the Family Health Program has improved health system performance in Brazil by reducing the number of potentially avoidable hospitalizations.

Non-adherence among patients initiating antiretroviral therapy: a challenge for health professionals in Brazil.

Objective:To assess the incidence, magnitude and factors associated with the first episode of non-adherence for 12 months after the first antiretroviral prescription. Design:A prospective study of HIV-infected patients receiving their first antiretroviral prescription in public referral centers, Belo Horizonte, Brazil. Baseline assessment occurred at the moment of the first prescription and follow-up visits at the first, fourth and seventh month, from May 2001 to May 2003. Methods:Non-adherence was self-reported and defined as the intake of less than 95% of the prescribed doses for 3 days before the follow-up interviews. Cumulative and person-time incidence were estimated and Coxs proportional model was used to assess the relative hazard (RH) of non-adherence with 95% confidence interval for both univariate and multivariate analysis. Results:Among 306 patients, the cumulative incidence of non-adherence was 36.9% (incidence rate 0.21/100 person-days). Multivariate analysis (P < 0.05) showed that unemployment (RH = 2.17), alcohol use (RH = 2.27), self-report of three or more adverse reactions (RH = 1.64), number of pills per day (RH = 2.04), switch in antiretroviral regimen (RH = 2.72), and a longer time between the HIV test result and the first antiretroviral prescription (RH = 2.27) were associated with an increased risk of non-adherence, whereas the use of more than one health service indicated a negative association (RH = 0.54). Conclusion:The current analysis has pointed out the importance of clinical and health service characteristics as potential indicators of non-adherence after initiating therapy. Early assessment and intervention strategies should be priorities in these AIDS public referral centres. Feasible and reliable indicators for the routine monitoring of adherence should be incorporated in clinical practice.

Adesão à terapia anti-retroviral (HIV/aids): fatores associados e medidas da adesão

Summary There is a universal tendency for a qualitative change on the clinical-laboratory approach of patients under treatment for HIV/AIDS. The antiretroviral therapy (ARVT) in Brazil, such as succeeded in industrialized countries of Northern Hemisphere which adopted universal access to this treatment, has brought benefits indicated by longer survival time and declines of AIDS-related morbidity and mortality. This article presents a literature review related to adherence to ARVT. Fifty-six articles were found related to the following categorized variables: socio-economic characteristics; vulnerability to HIV; utilization of health services; and ARVT. The main overall conclusion abstracted from the studies is the necessity of a continuum monitoring of patients. The initial treatment is critical and in order to create a bound with patients, it is necessary to focus on individual follow-up, social support and counseling about AIDS. Reference health services on HIV/AIDS have to closely monitor patients right after the beginning of HIV-treatment, in order to avoid potential barriers, to optimize good experiences, and to increment adherence to antiretrovirals.

High incidence of adverse reactions to initial antiretroviral therapy in Brazil

A concurrent prospective study was conducted from 2001 to 2003 to assess factors associated with adverse reactions among individuals initiating antiretroviral therapy at two public referral HIV/AIDS centers in Belo Horizonte, MG, Brazil. Adverse reactions were obtained from medical charts reviewed up to 12 months after the first antiretroviral prescription. Cox proportional hazard model was used to perform univariate and multivariate analyses. Relative hazards (RH) were estimated with 95% confidence intervals (CI). Among 397 charts reviewed, 377 (95.0%) had precise information on adverse reactions and initial antiretroviral treatment. Most patients received triple combination regimens including nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors. At least one adverse reaction was recorded on 34.5% (N = 130) of the medical charts (0.17 adverse reactions/100 person-day), while nausea (14.5%) and vomiting (13.1%) were the most common ones. Variables independently associated with adverse reactions were: regimens with nevirapine (RH = 1.78; 95% CI = 1.07-2.96), indinavir or indinavir/ritonavir combinations (RH = 2.05; 95% CI = 1.15-3.64), female patients (RH = 1.93; 95% CI = 1.31-2.83), 5 or more outpatient visits (RH = 1.94; 95% CI = 1.25-3.01), non-adherence to antiretroviral therapy (RH = 2.38; 95% CI = 1.62-3.51), and a CD4+ count of 200 to 500 cells/mm3 (RH = 2.66; 95% CI = 1.19-5.90). An independent and negative association was also found for alcohol use (RH = 0.55; 95% CI = 0.33-0.90). Adverse reactions were substantial among participants initiating antiretroviral therapy. Specially elaborated protocols in HIV/AIDS referral centers may improve the diagnosis, management and prevention of adverse reactions, thus contributing to improving adherence to antiretroviral therapy among HIV-infected patients.

Análisis coste-efectividad de la adhesión inicial a la terapia antirretroviral entre individuos infectados por el VIH en Belo Horizonte, Brasil

Fundamento: En Brasil, los antirretrovirales (ARV) se distribuyen a los portadores de VIH de forma gratuita por el Sistema Unico de Salud. La adhesion al tratamiento es una de las principales variables en la cual los servicios de salud pueden intervenir para aumentar la efectividad de la medicacion. El objetivo del estudio es evaluar la relacion coste-efectividad de la adhesion inicial a la terapia ARV e identificar factores que influencien los costes y la evolucion global del paciente. Metodos: Estudio prospectivo con individuos infectados por el VIH reclutados, despues de la primera prescripcion de ARV, en dos servicios publicos de referencia para el tratamiento del VIH/Sida en Brasil. La no-adhesion fue definida como la utilizacion 200 cels/mm3 y ser adherente al tratamiento ARV. Conclusiones: Los resultados observados sostienen la terapia ARV como una intervencion coste-efectiva. Sin embargo, la baja adhesion aumenta los riesgos de fallo terapeutico y de progresion de la enfermedad, que resultan en un impacto negativo sobre la relacion coste-efectividad de la terapia ARV.

Gender differences in non-adherence among Brazilian patients initiating antiretroviral therapy

OBJECTIVE: We conducted a study to identify gender differences in factors associated with the first episode of non-adherence in the 12 months following the first antiretroviral prescription. METHODS: A concurrent prospective study of patients initiating antiretroviral therapy in Brazil was conducted from 2001-2002. The self-reported measurement of adherence was defined as an intake of less than 95% of the prescribed number of doses. Only the first occurrence of non-adherence was considered in this analysis. All analyses were stratified by gender. A Cox proportional hazard model was used to estimate the risk of non-adherence, and the time to non-adherence was estimated using the Kaplan-Meier method. RESULTS: The cumulative incidence of non-adherence was 34.6% (29.7% and 43.9% among men and women, respectively; p = 0.010). Marital status (being married or in stable union; p = 0.022), alcohol use in the month prior to the baseline interview (p = 0.046), and current tobacco use (p = 0.005) increased the risk of non-adherence among female participants only, whereas a self-reported difficulty with the antiretroviral treatment was associated with non-adherence in men only. For both men and women, we found that a longer time between the HIV test and first antiretroviral therapy prescription (p = 0.028) also presented an increased risk of non-adherence. CONCLUSIONS: In this cohort study, the incidence of non-adherence was 1.5 times greater among women compared to men. Our results reinforce the need to develop interventions that account for gender differences in public referral centers. Additionally, we emphasize that, to achieve and maintain appropriate adherence levels, it is important to understand the barriers to seeking and utilizing health care services.

Interações sociais e a adesão à terapia antirretroviral de pessoas vivendo com HIV/AIDS

Apesar do aumento de acessibilidade aos regimes de tratamento antirretrovirais, a adesao continua a ser um desafio para os sistemas de saude no Brasil. Dificuldades relacionadas a baixa adesao entre os pacientes que vivem com HIV/ Aids incluem a adaptacao ao tratamento e interacoes sociais mais pobres, devido, geralmente, ao estigma da doenca. Esses e outros aspectos psicossociais dos individuos sao expressos em suas interacoes sociais, objeto deste estudo qualitativo. Os participantes foram pacientes de servicos de referencia para o tratamento do HIV. Realizaram-se 30 entrevistas, sendo definidas categorias empiricas a partir da analise de conteudo realizada. Observou-se que os pacientes que se distanciaram de seus parceiros, familia, amigos e vizinhos, em oposicao a partilhar a sua experiencia com a doenca, experimentaram diminuicao de apoio de sua rede social. Esses dados salientaram a necessidade de melhorar a educacao do paciente e incentivar intervencoes mais eficientes, favorecendo o trabalho multidisciplinar e uma abordagem integrada dos cuidados de saude, para promover maior adesao ao tratamento

The user's view related to quality of care of an emergency department

Objetivo: Avaliar os fatores associados com a qualidade do atendimento de uma Unidade de Pronto Atendimento (UPA) na perspectiva do usuário. Método: Potenciais associações entre qualidade da UPA e fatores sociodemográficos, de utilização e de avaliação da unidade foram verificadas pelo teste do Qui-Quadrado de Pearson. Realizou-se também a análise qualitativa com o uso da técnica de Análise de Conteúdo. Resultados: Observou-se associação significativa entre a qualidade do atendimento da UPA e idade, satisfação com o atendimento da recepção, enfermagem e do médico e a classificação da higiene e ambiente. A relação entre usuários e profissionais de saúde e funcionários foi retratada como um forte motivo para a insatisfação. Conclusão: Apesar da classificação geral positiva (73,1%), os depoimentos dos usuários levantaram temas que devem ser reavaliados pela gestão para refletirem em aperfeiçoamento dessa unidade. Palavras-chave: Medicina de Urgência; Garantia da Qualidade dos Cuidados de Saúde; Comportamento do Consumidor. RESUMO Revista Médica de Minas Gerais

Relationship between health behaviors and self-reported diseases by public employees

Introducao: Os habitos de vida como a pratica de atividade fisica, o lazer, os habitos alimentares, o estresse, o tabagismo e etilismo podem implicar diretamente nas condicoes de saude do individuo. Objetivo: Este trabalho teve como objetivo verificar a relacao entre comportamentos em saude e as doencas autorreferidas por servidores de uma universidade publica federal da regiao sudeste. Metodos: Participaram do estudo 815 servidores, sendo 347 docentes e 468 tecnico-administrativos, com idade de 20 a 65 anos. Trata-se de um estudo transversal. Os dados deste estudo foram coletados de um banco de dados secundario, provenientes do Questionario de Saude (condicoes de saude autorreferidas por docentes e tecnico-administrativos), da Pro-Reitoria de Assuntos Comunitarios da Instituicao. Dentre as variaveis avaliadas, foi verificada a relacao entre o habito alimentar, a pratica de atividade fisica, o tabagismo e o consumo de bebida alcoolica com as doencas autorreferidas (doencas cronicas nao transmissiveis e doencas infecto-parasitarias, diagnosticadas pelo medico nos ultimos 12 meses). Resultados: A media de doencas entre esses docentes e tecnico-administrativos da pesquisa foi de 3,1 e 2,9, respectivamente. Destacou-se nesse estudo a associacao estatisticamente significante da alimentacao nao saudavel com o acidente vascular encefalico; a atividade fisica irregular/sedentarismo com as doencas endocrinas/nutricionais/metabolicas e do aparelho digestivo; o excesso de peso com as doencas cardiovasculares, doencas endocrinas/nutricionais/metabolicas, diabetes mellitus e hipertensao arterial sistemica; e o tabagismo com as doencas osteomusculares. Conclusao: Sugere-se a adocao de medidas de prevencao e controle dos comportamentos de risco entre esses servidores.