Pauline Lorena Kale

O mercado de planos e seguros de saúde no Brasil: uma abordagem exploratória sobre a estratificação das demandas segundo a PNAD 2003

A partir dos dados do Suplemento Saude da PNAD 1998, diversos estudos evidenciaram a presenca de diferencas significativas nos padroes socioeconomicos, acesso, utilizacao de servicos de saude e condicoes de saude entre os segmentos populacionais cobertos e nao cobertos por planos de saude. Buscando contribuir para aprimorar o acervo dos conhecimentos sobre a estrutura e a dinâmica do mercado de planos e seguros de saude no Brasil, admite-se e procura-se evidenciar a heterogeneidade dessas demandas. Para tanto, foi definida uma tipologia de planos de saude, fundamentada nas origens institucionais das demandas e, subsequentemente, pelas relacoes de dependencia com titulares de planos e seguros de saude, integrada por tres categorias principais: os planos empresariais privados, os planos empresariais publicos e os planos individuais. As caracteristicas etarias, socioeconomicas e de condicoes de saude variam segundo os diferentes tipos de plano, sugerindo a presenca de padroes distintos de demandas, especialmente entre os planos empresariais privados e os planos individuais.

Detecção precoce de epidemias de malária no Brasil: uma proposta de automação

Summary In Brazil, 99% of reported malaria cases occur in the Amazon Region. To date, however, an automated system has not yet been defined to detect epidemics in this area. This study proposes several statistical methods that could be useful for early detection of malaria epidemics. Five types of graphs were investigated: average +1.96 standard deviations (Cullen method); inter-quartile range (Albuquerque method); 3rd quartile method; Cusum-tabular method; and smoothing of baselines (Stern & Lightfoot method). The true alarm rate (TAV) detected by these methods was as follows: 100% by all five methods in the Municipality of Manaus, Amazonas State; and in the Municipality of Machadinho D’Oeste, Rondonia State 100% were detected by the 3rd quartile method; 25% using the Cullen, and Stern & Lightfoot methods, and 0% for other methods. In the Municipality of Amarante do Maranhao, Maranhao State, there were no epidemic months, and no alarm was given by any of the five methods, corresponding to 100% success. The 3rd quartile method is the most appropriate for early detection of malaria epidemics in municipal districts of the Brazilian Amazon Region, and recommended for implantation in routine malaria surveillance. Key-words: malaria; epidemics; epidemiology surveillance; statistical graphs.

Temporal pattern of diarrhea hospitalizations and deaths in children, 1995 to 1998, Brazil

OBJECTIVE To analyze the temporal pattern of hospitalization and deaths due to diarrhea among children less than five years old between 1995 and 1998 to support specific prevention actions and disease control strategies. METHODS Data was collected from the Ministry of Healths Mortality Data System and Hospitalization Data System. Monthly time series of diarrhea hospitalizations and deaths were decomposed into stochastic linear trend, deterministic seasonal and irregular components using structural time series models. RESULTS The levels of both series showed a decline in time. This pattern being more evident in the hospitalization series. The slope variation was constant in both series; on average less than 5.3 hospitalizations/month (p-value <0.001), and less than 1 death/month (p-value <0.1). The residual analysis of the hospitalization series revealed a positive trend change in January 1996. The seasonal component for both models was statistically significant (p-value <0.0001) with May and June as months of highest hospitalizations and deaths. Normality and time independence assumptions of errors could not be rejected at a 0.05 significance level. CONCLUSIONS The temporal pattern of moderate and severe diarrhea described and estimated in this study suggests that rotavirus might be a predominant disease agent. In this context, targeted vaccination is recommended for prevention and control. However, further studies on the efficacy of rotavirus candidate vaccines are necessary in order to implement this strategy in Brazil.

Série temporal de características maternas e de nascidos vivos em Niterói, RJ

OBJECTIVES: to describe the tendency over time of characteristics of the mother, care provided and newborns, in Niteroi, a city in the Brazilian State of Rio de Janeiro. METHODS: an ecological time-series study from 2000 to 2009. Data were gathered from the Live Birth Information System (SINASC). Annual variations were described in age, schooling and reproductive history of mother, prenatal care, kind of delivery, color, birth weight and gestational age. RESULTS: the completeness of information was high among the 62,449 live newborns studied. Births fell and primiparity increased. There was reduction in pregnancies among adolescents (2.3% per year) and an increase in mothers aged over 35 years. Schooling improved, with a decrease in the percentage of pregnant women with less than eight years of school. Around 80% of women had attended seven or more prenatal sessions. Caesarean births tended to increase in frequency, with 67.7% of woman having one of these in 2009. Low birth weight showed a tendency to fall by 1.1% per year. Prematurity increased by 7.4 to 7.9%. CONCLUSIONS: there were positive demographic and social changes in Niteroi. Birth weight was not much affected by prematurity. As in other locations in Brazil, there has been an increase in the number of women undergoing Caesarian sections.

Análise da sobrevida infantil segundo características maternas, da gestação, do parto e do recém nascido na coorte de nascimento de 2005 no Município do Rio de Janeiro-RJ, Brasil

Objective: to investigate associations between infant survival and maternal, pregnancy, parturition and newborn characteristics, in the birth cohort of 2005, in the municipality of Rio de Janeiro, state of Rio de Janeiro, Brazil. Methods: a retrospective cohort study, carried out using data from Live Birth Information System (Sinasc) and Mortality Information System (SIM); probability of infant survival was estimated using tactuarial life table and Kaplan-Meier methods. Results: the probability of infant survival was estimated in 0.9861; highest probabilities of death were found among babies born to mothers aged under 20 years (0.0148), by vaginal delivery (0.0146), male (0.0154), weighing under 2,500g (0.0861) and premature (0.0992); about 65.0% of these deaths could be avoided improving perinatal care health services. Conclusion: the use of National information systems data is an important tool to define maternal and child policies.

Qualidade da informação sobre mortalidade numa coorte de diabéticos - Estado do Rio de Janeiro, 2000 a 2003

OBJECTIVE The aim of this study was to demonstrate the quality of the National Mortality Information System (SIM) in a special cohort of inpatients submitted to lower limb amputation (LLA) as a result of diabetes mellitus (DM), and compare the mortality pattern by causes for the cohort and for the population base of the State of Rio de Janeiro, from 2000 to 2003. METHODS Data were generated from the linkage of the National Hospital Admittance Authorization-SIH-SUS (2000) and SIM (2000-2003) databases. Individuals under 30 years were excluded from the study, and deaths due to violent causes were also excluded in order to analyze the mention of DM as cause of death. Analyses of causes of death were conducted both in the cohort and the population base. Quality markers of SIM in the cohort were the frequency of mention of diabetes mellitus in the death certificate and the proportion of deaths classified as non-specific causes of death, and non-specific causes of death in the population base. RESULTS 38.0% in the special cohort (n = 977) died during the four years following LLA as a result of diabetes mellitus (DM), and 49.1% of these deaths occurred during the first year. Endocrine, nutritional metabolic (41.5%), and cardiovascular diseases (28.5%), and non-specific causes of death (8.1%) were the main underlying causes of death (UC). DM was mentioned as UC for 41.0%, as a sequential cause for 1.6%, and as contributive cause for 10.0%, among the other natural underlying causes of death besides DM on death certificates. Non-specific underlying causes of death accounted for 11.8% of death certificates in the population base. CONCLUSIONS The high risk of death, the causes of death and the underreporting of DM on death certificates of adults with diabetes were similar to other population-based mortality studies. In the special cohort, the quality of the causes of death on certificates was considered bad. The improvement in the reliability of cause-of-death depends on the ability of physicians to register, and of healthcare facilities to codify correctly the causes of death on death certificates. The method (linkage of data and multiple causes of death) applied in this study to qualify death information was efficient and effective.

Ecological analysis of the relationship between infant mortality and cardiovascular disease mortality at ages 45-69 in the Brazilian 1935 birth cohort.

BACKGROUND International ecological studies have shown a positive association between infant mortality as a proxy for low birth weight and cardiovascular disease mortality in adult life. METHODS Mortality rates due to Cardiovascular Diseases (CVDMR) standardised by age in adults between 45 and 69 years of age and by place of birth (pob) and residence (res) were related to Infant Mortality Rates (IMR) in the Brazilian 1935 birth cohort. RESULTS Two relationship patterns were noted between IMR and CVDMR: for the Southeast, South and Centre-West group of regions (r(pob)=0.46; r(res)=0.29) and for the North and Northeast group of regions (r(pob)=0.21; r(res)=0.33). For the latter pattern, two states were identified (Rio Grande do Norte and Paraíba) as atypical areas, whose exclusion strengthened the association (r(pob)=0.73; r(res)=0.91). CONCLUSIONS The direction of the associations changed after the analysis by group of Brazilian regions (indirect control of socio-economic levels, coverage and quality of the information). There is a positive, although weak association between IMR and CVDMR. Attempts to control or minimise the interference of migratory movements, cohort effects and socio-economic levels represented methodological progress in ecological analyses of foetal programming in Brazil.

Risk groups in children under six months of age using self-organizing maps

Fetal and infant growth tends to follow irregular patterns and, particularly in developing countries, these patterns are greatly influenced by unfavorable living conditions and interactions with complications during pregnancy. The aim of this study was to identify groups of children with different risk profiles for growth development. The study sample comprised 496 girls and 508 boys under six months of age from 27 pediatric primary health care units in the city of Rio de Janeiro, Brazil. Data were obtained through interviews with the mothers and by reviewing each childs health card. An unsupervised learning, know as a self-organizing map (SOM) and a K-means algorithm were used for cluster analysis to identify groups of children. Four groups of infants were identified. The first (139) consisted of infants born exclusively by cesarean delivery, and their mothers were exclusively multiparous; the highest prevalences of prematurity and low birthweight, a high prevalence of exclusive breastfeeding and a low proportion of hospitalization were observed for this group. The second (247 infants) and the third (298 infants) groups had the best and worst perinatal and infant health indicators, respectively. The infants of the fourth group (318) were born heavier, had a low prevalence of exclusive breastfeeding, and had a higher rate of hospitalization. Using a SOM, it was possible to identify children with common features, although no differences between groups were found with respect to the adequacy of postnatal weight. Pregnant women and children with characteristics similar to those of group 3 require early intervention and more attention in public policy.

Critérios pragmáticos da definição de near miss neonatal: um estudo comparativo

ABSTRACT OBJECTIVE The objective of this study was to test the validity of the pragmatic criteria of the definitions of neonatal near miss, extending them throughout the infant period, and to estimate the indicators of perinatal care in public maternity hospitals. METHODS A cohort of live births from six maternity hospitals in the municipalities of São Paulo, Niterói, and Rio de Janeiro, Brazil, was carried out in 2011. We carried out interviews and checked prenatal cards and medical records. We compared the pragmatic criteria (birth weight, gestational age, and 5’ Apgar score) of the definitions of near miss of Pileggi et al., Pileggi-Castro et al., Souza et al., and Silva et al. We calculated sensitivity, specificity (gold standard: infant mortality), percentage of deaths among newborns with life-threatening conditions, and rates of near miss, mortality, and severe outcomes per 1,000 live births. RESULTS A total 7,315 newborns were analyzed (completeness of information > 99%). The sensitivity of the definition of Pileggi-Castro et al. was higher, resulting in a higher number of cases of near miss, Souza et al. presented lower value, and Pileggi et al. and de Silva et al. presented intermediate values. There is an increase in sensitivity when the period goes from 0–6 to 0–27 days, and there is a decrease when it goes to 0–364 days. Specificities were high (≥ 97%) and above sensitivities (54% to 77%). One maternity hospital in São Paulo and one in Niterói presented, respectively, the lowest and highest rates of infant mortality, near miss, and frequency of births with life-threatening conditions, regardless of the definition. CONCLUSIONS The definitions of near miss based exclusively on pragmatic criteria are valid and can be used for monitoring purposes. Based on the perinatal literature, the cutoff points adopted by Silva et al. were more appropriate. Periodic studies could apply a more complete definition, incorporating clinical, laboratory, and management criteria, including congenital anomalies predictive of infant mortality.OBJETIVO Testar a validade dos criterios pragmaticos de definicoes de near miss neonatal, estendendo-as para todo o periodo infantil, e estimar indicadores de assistencia perinatal em maternidades publicas. METODOS Constituiu-se uma coorte de nascidos vivos de seis maternidades dos municipios de Sao Paulo, Niteroi e Rio de Janeiro em 2011. Foram realizadas entrevistas e consultas […]

Incidence of congenital syphilis in a metropolitan region of Rio de Janeiro state: social inequalities

Introduction: congenital syphilis remains a public health matter, with no perspective of reaching governmental reduction goals. There are few studies about social inequalities and its relation with this disease in Brazil. Objective: describe occurrence of congenital syphilis in a reference hospital in a Metropolitan Region of Rio de Janeiro State, according to socioeconomic and clinical-laboratorial variables as well. Methods: cross-sectional study, based on interviews, review of medical records and prenatal cards. Population: all women admitted to a maternity ward during a trimester in 2011. Maternal variables: age, schooling, skin color, income, prenatal visits. Fetus/neonate variables: birth weight, gestational age, clinical and laboratory outcomes. Incidence of congenital syphilis (Brazilian Ministry of Health criteria) was calculated for all live births and for each social and economical variable. Results: there were 666 eligible women, comprehending 576 deliveries – 558 live births and 18 stillbirths. We identified 22 CS cases: 18 live births, three fetal deaths and 1 abortion. One of the neonates died in the third day of life. The incidence of CS was of 39.4/1,000 live births. Socioeconomic variables – low education, low income and black skin – were related to a greater incidence. Only 13 out of 22 cases were identified in prenatal care. Conclusion: our results pointed to social inequalities in the congenital syphilis incidence. As prenatal care is also related to socioeconomic variables, investments in quality of maternal assistance should be directed to more vulnerable women.