Telma Ruth Pereira

A sustentabilidade econômico-financeira no Proesf em municípios do Amapá, Maranhão, Pará e Tocantins

Nos estudos de linha de base do Projeto de Expansao do Programa Saude da Familia (Proesf), o artigo trata do tema do financiamento do Programa de Saude da Familia (PSF) na otica de sua sustentabilidade financeira. Aspectos relativos a construcao de medidas e indicadores de sustentabilidade sao abordados a partir da experiencia recente de diferenciacao da politica de incentivos financeiros do SUS aos municipios de mais de 100 mil habitantes no Brasil atraves do Proesf. A sugestao de inclusao destes indicadores apenas permite definir a coerencia a longo prazo das acoes planejadas do ponto de vista de financiamento. O tema, entretanto, nao esgota a necessidade de revisao critica dos criterios hoje utilizados pela politica de incentivos do PSF e de sua diferenciacao entre municipios, que nao se deriva exclusivamente do porte municipal. As diferencas de situacoes municipais quanto a sustentabilidade, apontadas no estudo, chamam a atencao para os limites e limitacoes da aplicacao de politicas homogeneas para situacoes desiguais, com consequencias previsiveis sobre a manutencao e agravamento da iniquidade.

Avaliação de competências de médicos e enfermeiros das Equipes de Saúde da Família da Região Norte do Brasil

Trata-se de um estudo quantitativo, realizado com base na analise de questionarios aplicados a medicos e enfermeiros dos Estados do Maranhao, Tocantins, Para e Amapa, no ano de 2006. A pesquisa e parte integrante do Projeto de Expansao do Programa de Saude da Familia (PROESF), subsidiado pela Fundacao Cesgranrio. Foram respondidos 346 questionarios, sendo 160 por medicos e 186 por enfermeiros. Dentre os resultados encontrados, esta o fato de que medicos e enfermeiros que trabalham na Saude da Familia da Regiao Norte estabelecem um perfil profissional de competencia onde ha necessidades especificas de educacao permanente. Conclui-se, portanto, que a mera adesao a Estrategia de Saude da Familia nao garante por si so a dinâmica e o sucesso das acoes voltadas a reorganizacao da rede, a melhoria da gestao e aperfeicoamento da gerencia do SUS. Alem disso, a capacitacao profissional e precaria frente a demanda de formacao exigida.

Vascular Health Assessment of The Hypertensive Patients (VASOTENS) Registry: Study Protocol of an International, Web-Based Telemonitoring Registry for Ambulatory Blood Pressure and Arterial Stiffness

Background Hypertension guidelines recommend ambulatory blood pressure (ABP), central aortic pressure (CAP), and pulse wave velocity (PWV) as parameters for estimating blood pressure (BP) control and vascular impairment. Recent advances in technology have enabled devices to combine non-invasive estimation of these parameters over the 24-hour ABP monitoring. However, currently there is limited evidence on the usefulness of such an approach for routine hypertension management. Objective We recently launched an investigator-initiated, international, multicenter, observational, prospective study, the Vascular health Assessment Of The Hypertensive patients (VASOTENS) Registry, aimed at (1) evaluating non-invasive 24-hour ABP and arterial stiffness estimates (through 24-hour pulse wave analysis, PWA) in hypertensive subjects undergoing ambulatory blood pressure monitoring (ABPM) for clinical reasons; (2) assessing the changes in estimates following treatment; (3) weighing the impact of 24-hour PWA on target organ damage and cardiovascular prognosis; (4) assessing the relationship between arterial stiffness, BP absolute mean level and variability, and prognosis; and (5) validating the use of a 24-hour PWA electronic health (e-health) solution for hypertension screening. Methods Approximately 2000 subjects, referred to 20 hypertension clinics for routine diagnostic evaluation and follow-up of hypertension of any severity or stage, will be recruited. Data collection will include ABPM, performed with a device allowing simultaneous non-invasive assessment of 24-hour CAP and arterial stiffness (BPLab), and clinical data (including cardiovascular outcomes). As recommended by current guidelines, each patient will be followed-up with visits occurring at regular intervals (ideally every 6 months, and not less than once a year depending on disease severity). A Web-based telemedicine platform (THOLOMEUS) will be used for data collection. The use of the telemedicine system will allow standardized and centralized data collection, data validation by experts and counseling to remote centers, setup and maintenance of the Registry, and prompt data analysis. Results First follow-up results are expected to be available in the next 2 years. Conclusions The results of the VASOTENS Registry will help define the normalcy thresholds for current and future indices derived from 24-hour PWA, according to outcome data, and will also provide supporting evidence for the inclusion of this type of evaluation in hypertension management. Trial registration Clinicaltrials.gov NCT02577835; https://clinicaltrials.gov/ct2/show/NCT02577835 (Archived by WebCite at http://www.Webcitation.org/6hzZBKY2Q)

Notas sobre o futuro do SUS: breve exame de caminhos e descaminhos trilhados em um horizonte de incertezas e desalentos

This article reflects on the future of the Brazilian Unified Health System (SUS, acronym in Portuguese), based on the foresight exercises conducted by the Brasil Saúde Amanhã initiative of the Oswaldo Cruz Foundation. The text briefly reviews some paths followed by the SUS as referred to in the Federal Constitution of 1988. It highlights the movement towards the decentralization of care and the constraint of health financial resources that reduced policies of increasing public expenditures. It examines the public and private arrangements for financing and provision of services that have resulted in sectoral privatization, mainly from economic policies articulated with concession of fiscal benefits. It analyzes the changes in the public sector financing through successive constitutional amendments that resulted in the weakening of established social protection policies, particularly of the health sector. For the future, the text considers population aging and analyzes trends in the epidemiological profile, with consequent changes in the health care paradigm. The article concludes by pointing out the consequences of fiscal strangling in the organization of the healthcare system and the need to reverse legal provisions that hamper the fulfillment of the constitutional mandate for equity and universality.Resumo Este artigo apresenta uma reflexao sobre o futuro do SUS, baseada em exercicios prospectivos desenvolvidos pela iniciativa Brasil Saude Amanha da Fundacao Oswaldo Cruz. O texto faz uma breve revisao de caminhos e descaminhos percorridos pelo SUS, tendo como marco a Constituicao Federal de 1988. Destaca os movimentos pela descentralizacao e a subtracao de recursos da saude que reduziu a politica de incremento de gastos; e acentua os arranjos publicos e privados de financiamento e provisao de servicos que resultaram na privatizacao setorial decorrente, principalmente, de politicas economicas articuladas com a concessao de beneficios e tributos. Analisa o financiamento do setor publico atraves das sucessivas emendas constitucionais que resultaram na destruicao da protecao social e no enfraquecimento do setor Saude. Para o futuro, o texto considera o envelhecimento populacional e analisa tendencias no perfil epidemiologico, com as consequentes mudancas no modelo de cuidados de atencao a saude. O artigo conclui apontando os resultados do estrangulamento fiscal na organizacao do sistema de cuidados e a necessidade da reversao de dispositivos legais que obstaculizam o mandamento constitucional.

[PP.09.20] AMBULATORY VASCULAR INDEX: A NOVEL MEASURE OF ARTERIAL STIFNNESS IN AMBULATORY CONDITIONS OVER THE 24-HOUR

Objective: The current hypertension management involves both ambulatory blood pressure (BP) monitoring (ABPM) and evaluation of the arterial stiffness by measuring pulse wave velocity (PWV). Stiffness parameter &bgr; is a promising estimate of arterial stiffness characterized by a less dependency on BP. &bgr; is used to calculate the well-known cardio-ankle vascular index (CAVI), which is measured in the segment between heart and ankle. However, at present, CAVI may be obtained only at rest and thus may not return information on arterial stiffness in the dynamic conditions of everyday life. Recently available technologies now allow 24-h pulse wave analysis (PWA) integrated in ABPM devices and may provide an easy way to obtain PWV. They can also make possible to evaluate &bgr; in the corresponding segment and ambulatory BP in a single procedure. For methodological analogy with CAVI we decided to call new index AVI, which means Ambulatory Vascular Index. The aim of this part of the pilot study is to evaluate the features of the AVI in healthy volunteers. Design and method: Data of 179 healthy volunteers (BP and PWV) were collected with BPLab® ABPM device and validated Vasotens® PWA technology. AVI is calculated using BP and PWV of each measurement and then averaged for 24-h period. We used following formula: AVI = 2&rgr;/&dgr;P[lnPs/Pd]PWV2, where &rgr;: blood density, &dgr;P: Ps-Pd or systolic minus diastolic BP. Results: 24-h average AVI in volunteers was 15.4 ± 3.8, while 24-h average PWV was 9.3 ± 1.1 m/s (mean ± SD). Figure. No caption available. There was no correlation between AVI and 24-h systolic BP (r = −0.02, n/s, fig.1, a), but 24-h PWV was significantly associated with SBP (r = 0.36, p < 0.05, fig.1, b). Both AVI and PWV were significantly related with age (r = 0.43, p < 0.05 and r = 0.42, p < 0.05, fig.1 c and d respectively). Conclusions: Our pilot study suggests that the AVI is a feasible estimate of arterial stiffness, with the advantage of being independent on BP. However, further study of the AVI feasibility, methods of calculation, and the role in integrated approach for evaluating aortic stiffness in relation to cardiovascular risk, are needed. AVI may be interpreted in similar way like other age-dependent indices of arterial stiffness.

[OP.7D.07] 24-HOUR CENTRAL BLOOD PRESSURE IS BETTER ASSOCIATED WITH TARGET ORGAN DAMAGE OF HYPERTENSION THAN BRACHIAL BLOOD PRESSURE

Objective: The VASOTENS international, multicenter, observational, non-randomized, prospective study aims at evaluating the impact of 24-hour pulse wave analysis of ambulatory blood pressure (BP) recordings on target organ damage and cardiovascular prognosis of hypertensive patients. In the present analysis of study baseline data we checked whether organ damage of hypertension i) is better associated with 24-hour central than peripheral BP and ii) is related to ambulatory arterial stiffness, estimated by pulse wave velocity (PWV) and augmentation index (AIx). Design and method: In 334 hypertensive patients (mean age 53+/−15, 52% males, 45% treated) we obtained 24-hour ABPMs, echocardiograms, carotid ultrasonograms and serum creatinine. Hypertensive organ damage was estimated by calculation of left ventricular mass index (LVMI, cardiac damage), intima-media thickness (IMT, vascular damage) and creatinine clearance (CC, renal damage). 24-hour hemodynamics and stiffness were estimated through the validated VASOTENS technology, based on transfer function analysis of brachial oscillograms. 24-hour brachial (bSBP) and aortic systolic BP (aSBP), standard deviation of bSBP, PWV and AIx were obtained. Relation of vascular indices with LVMI, IMT and CC was evaluated by bivariate and multivariate analysis (stepwise linear regression analysis). Results: In the bivariate analysis a statistically significant relation was found for age, bSBP and aSBP vs. LVMI and IMT (see table, correlation coefficients or r). IMT was also significantly related to SBP variability and arterial stiffness, whereas increasing age, SBP variability and AIx were significantly associated with a decline of renal function. Figure. No caption available. In the multivariate analysis, including all variables entered in the bivariate model, adjusted by sex, statistically significant (p < 0.001) association was observed for aSBP and age with LVMI (standardized regression coefficient 0.25 and 0.18, respectively), and for age with IMT (0.56) and CC (−0.53). Conclusions: In hypertensive patients age appears to be the major determinant of organ damage, with central SBP, and marginally peripheral SBP, PWV and AIx, also playing a significant role. Our results suggest that estimation of 24-hour central hemodynamics and arterial stiffness in ambulatory conditions may help improve the individualized assessment of the BP-associated organ damage of hypertension