Clinical outcomes and staff satisfaction after adoption of digital chest drainage system for minimally invasive lung resections.

Background: Digital chest drainage systems (DCDS) provide reliable pleural drainage while quantifying fluid output and air leak. However, the benefits of DCDS in the contemporary era of minimally invasive thoracic surgery and enhanced recovery after surgery (ERAS) protocols have not been fully investigated. Additionally, hospital and resident staff experiences after implementation of a DCDS have not been fully explored. The objective of this study was to evaluate the clinical outcomes and hospital staff experience after adoption of a DCDS for minimally invasive lung resections. Methods: A single-center retrospective review of patients who underwent minimally invasive lung resection (lobectomy, segmentectomy, and wedge resection) and received a DCDS from 11/1/2021 to 11/1/2022. DCDS patients were compared to sequential historical controls (3/1/2019-6/30/2021) who received a analog chest drainage system. For the analog system, chest tubes were removed when no bubbles were observed in the water seal compartment with Valsalva, cough, and in variable positions. With a DCDS, chest tubes were removed when the air leak was less than 30 cc/min for 8 hours, with no spikes. All patients followed an institutional ERAS protocol. Primary outcomes were length of stay (LOS) and chest tube duration. Hospital staff and residents were surveyed regarding their experience. Results: One hundred and twenty-four patients received DCDS, and 248 received an analog chest drainage system. There was a reduction in mean LOS (3.6 vs. 4.4 days, P=0.01) and chest tube duration (2.7 vs. 3.6 days, P=0.03) in the DCDS group. Hospital staff (n=77, 46% response rate) reported the DCDS easier to use (60%, P<0.001) and easier to care for patients with (65%, P<0.001) compared to the analog system. Surgical residents (n=28, 56% response rate) reported increased confidence in interpretation of air leak (75%, P<0.001) and decision-making surrounding chest tube removal (79%, P<0.001). Conclusions: Using a DCDS can reduce LOS and chest tube duration in the contemporary setting of minimally invasive lung resections and ERAS protocols. Increased confidence of resident decision-making for chest tube removal may contribute to improved outcomes.

Preoperative risk factors for anastomotic leak after esophagectomy with gastric reconstruction: A 6-year national surgical quality improvement (NSQIP) database analysis.

BACKGROUND: Anastomotic leak is a serious complication after esophagectomy that has been associated with worse outcomes. However, identifying patients at increased risk for anastomotic leak remains challenging. METHODS: Patients were included from the 2016 to 2021 National Surgical Quality Improvement Project database who underwent elective esophagectomy with gastric reconstruction for cancer. A multivariable logistic regression model was used to identify risk factors associated with anastomotic leak. RESULTS: A total of 4,331 patients were included in the study, of whom 647 patients experienced anastomotic leak (14.9%). Multivariable logistic regression revealed higher odds of anastomotic leak with smoking (adjusted odds ratio 1.24, confidence interval 1.02-1.51, P = .031), modified frailty index-5 score of 1 (adjusted odds ratio 1.44, confidence interval 1.19-1.75, P = .002) or 2 (adjusted odds ratio 1.52, confidence interval 1.19-1.94, P = .000), and a McKeown esophagectomy (adjusted odds ratio 1.44, confidence interval 1.16-1.80, P = .001). Each 1,000/µL increase in white blood cell count was associated with a 7% increase in odds of anastomotic leak (adjusted odds ratio 1.07, confidence interval 1.03-1.10, P = .0005). Higher platelet counts were slightly protective, and each 10,000/ µL increase in platelet count was associated with 2% reduced odds of anastomotic leak (adjusted odds ratio 0.98, confidence interval 0.97-0.99, P = .001). CONCLUSION: In this study, smoking status, frailty index, white blood cell count, McKeown esophagectomy, and platelet counts were all associated with the occurrence of anastomotic leak. These results can help to inform surgeons and patients of the true risk of developing anastomotic leak and potentially improve outcomes by providing evidence to improve preoperative characteristics, such as frailty.

Smoking, mortality, access to diagnosis, and treatment of lung cancer in Brazil.

INTRODUCTION: Lung cancer (LC) is a relevant public health problem in Brazil and worldwide, given its high incidence and mortality. Thus, the objective of this study is to analyze the distribution of smoking and smoking status according to sociodemographic characteristics and disparities in access, treatment, and mortality due to LC in Brazil in 2013 and 2019. METHOD: Retrospective study of triangulation of national data sources: a) analysis of the distribution of smoking, based on the National Survey of Health (PNS); b) investigation of LC records via Hospital-based Cancer Registry (HCR); and c) distribution of mortality due to LC in the Mortality Information System (SIM). RESULTS: There was a decrease in the percentage of people who had never smoked from 2013 (68.5%) to 2019 (60.2%) and in smoking history (pack-years). This was observed to be greater in men, people of older age groups, and those with less education. Concerning patients registered in the HCR, entry into the healthcare service occurs at the age of 50, and only 19% have never smoked. While smokers in the population are mainly Mixed-race, patients in the HCR are primarily White. As for the initial stage (I and II), it is more common in White people and people who have never smoked. The mortality rate varied from 1.00 for people with higher education to 3.36 for people without education. Furthermore, White people have a mortality rate three times higher than that of Black and mixed-race people. CONCLUSION: This article highlighted relevant sociodemographic disparities in access to LC diagnosis, treatment, and mortality. Therefore, the recommendation is to strengthen the Population-Based Cancer Registry and develop and implement a nationwide LC screening strategy in Brazil since combined prevention and early diagnosis strategies work better in controlling mortality from the disease and continued investment in tobacco prevention and control policies.

Enhanced recovery after surgery pathway leads to decreased length of stay for patients undergoing minimally invasive lung resection.

Background: Enhanced recovery after surgery (ERAS) protocols in thoracic surgery have been demonstrated to impact length of stay (LOS), complication rates, and postoperative opioid use. However, ERAS protocols for minimally invasive lung resections have not been well described. Given most lung resections are now performed minimally invasively, there is a gap in the literature regarding the efficacy of ERAS protocols in this setting. In this study, we analyzed patient outcomes following implementation of an ERAS protocol for minimally invasive lung resections. Methods: Outcome data was retrospectively collected for 442 patients undergoing minimally invasive lung resections between January 1st, 2015 and October 26th, 2021. Patients were divided into either a pre-ERAS (n=193) or ERAS (n=249) group. Primary outcomes included LOS, postoperative complications, intensive care unit (ICU) admission status, 30-day hospital readmissions, and 30-day mortality. Secondary outcomes included common postoperative complications required for the Society for Thoracic Surgeons (STS) database. Results: We observed an overall decrease in median LOS (4.0 vs. 3.0 days, P=0.030) and ICU admission status (15% vs. 7.6%, P=0.020) after implementation of our ERAS protocol. The difference in LOS was significantly lower for anatomic lung resections, but not non-anatomic resections. There was no difference in 30-day readmissions and a 0% mortality rate in both groups. Overall, there was a low complication rate that was similar between groups. Conclusions: The implementation of an ERAS protocol led to decreased LOS and decreased ICU admission in patients undergoing minimally invasive lung resection. Process standardization optimizes performance by providers by decreasing decision fatigue and improving decision making, which may contribute to the improved outcomes observed in this study.

Smoking, mortality, access to diagnosis, and treatment of lung cancer in Brazil / Tabagismo, mortalidade, acesso ao diagnóstico e tratamento de câncer de pulmão no Brasil

ABSTRACT INTRODUCTION Lung cancer (LC) is a relevant public health problem in Brazil and worldwide, given its high incidence and mortality. Thus, the objective of this study is to analyze the distribution of smoking and smoking status according to sociodemographic characteristics and disparities in access, treatment, and mortality due to LC in Brazil in 2013 and 2019. METHOD Retrospective study of triangulation of national data sources: a) analysis of the distribution of smoking, based on the National Survey of Health (PNS); b) investigation of LC records via Hospital-based Cancer Registry (HCR); and c) distribution of mortality due to LC in the Mortality Information System (SIM). RESULTS There was a decrease in the percentage of people who had never smoked from 2013 (68.5%) to 2019 (60.2%) and in smoking history (pack-years). This was observed to be greater in men, people of older age groups, and those with less education. Concerning patients registered in the HCR, entry into the healthcare service occurs at the age of 50, and only 19% have never smoked. While smokers in the population are mainly Mixed-race, patients in the HCR are primarily White. As for the initial stage (I and II), it is more common in White people and people who have never smoked. The mortality rate varied from 1.00 for people with higher education to 3.36 for people without education. Furthermore, White people have a mortality rate three times higher than that of Black and mixed-race people. CONCLUSION This article highlighted relevant sociodemographic disparities in access to LC diagnosis, treatment, and mortality. Therefore, the recommendation is to strengthen the Population-Based Cancer Registry and develop and implement a nationwide LC screening strategy in Brazil since combined prevention and early diagnosis strategies work better in controlling mortality from the disease and continued investment in tobacco prevention and control policies.

RESUMO INTRODUÇÃO O câncer de pulmão (CP) é um relevante problema de saúde pública no Brasil e no mundo, dada sua alta incidência e mortalidade. Assim, objetiva-se analisar a distribuição do tabagismo e da carga tabágica segundo características sociodemográficas e disparidades no acesso, no tratamento e na mortalidade por CP no Brasil, em 2013 e 2019. MÉTODO Estudo retrospectivo de triangulação de fontes de dados de abrangência nacional: a) análise da distribuição do tabagismo, baseada na Pesquisa Nacional de Saúde (PNS); b) investigação dos registros de CP, via Registros Hospitalares de Câncer (RHC); e c) distribuição da mortalidade por CP, no Sistema de Informação sobre Mortalidade (SIM). RESULTADOS Verificou-se redução do percentual de pessoas que nunca fumaram de 2013 (68,5%) para 2019 (60,2%), assim como da carga tabágica (anos-maço). Esta foi observada maior em homens em pessoas de faixas etárias mais avançadas e de menor escolaridade. Em relação aos pacientes registrados no RHC, a entrada no serviço de saúde se dá a partir de 50 anos, e apenas 19% nunca fumaram. Ao passo que os fumantes na população são majoritariamente pardos, os pacientes no RHC são em maioria brancos. Quanto ao estadiamento inicial (I e II), é mais frequente em pessoas brancas e que nunca fumaram. A taxa de mortalidade apresentou variação de 1,00, para pessoas com ensino superior, a 3,36, entre pessoas sem instrução, assim como pessoas brancas têm uma taxa de mortalidade três vezes maior que a de pessoas negras e pardas. CONCLUSÃO Este artigo apontou relevantes disparidades sociodemográficas no acesso ao diagnóstico, tratamento e mortalidade do CP. Assim, recomenda-se: fortalecer o Registro de Câncer de Base Populacional; desenvolver e implementar estratégia de screening de CP no Brasil, uma vez que a realização de estratégias de prevenção e diagnóstico precoce combinadas funcionam melhor no controle da mortalidade pela doença; e investimento contínuo nas políticas de prevenção e controle do tabagismo.

Lung Cancer Screening in Brazil Comparing the 2013 and 2021 USPSTF Guidelines.

Importance: It is estimated that, from 2023 to 2025, lung cancer (LC) will be the second most frequent cancer in Brazil, but the country does not have an LC screening (LCS) policy. Objective: To compare the number of individuals eligible for screening, 5-year preventable LC deaths, and years of life gained (YLG) if LC death is averted by LCS, considering 3 eligibility strategies by sociodemographic characteristics. Design, Setting, and Participants: This comparative effectiveness research study assessed 3 LCS criteria by applying a modified version of the LC-Death Risk Assessment Tool (LCDRAT) and the LC-Risk Assessment Tool (LCRAT). Data are from the 2019 Brazilian National Household Survey. Participants included ever-smokers aged 50 to 80 years. Data analysis was performed from February to May 2023. Exposures: Exposures included ever-smokers aged 50 to 80 years, US Preventive Services Task Force (USPSTF) 2013 guidelines (ever-smokers aged 55 to 80 years with ≥30 pack-years and <15 years since cessation), and USPSTF 2021 guidelines (ever-smokers aged 50 to 80 years with 20 pack-years and <15 years since cessation). Main Outcomes and Measures: The primary outcomes were the numbers of individuals eligible for LCS, the 5-year preventable deaths attributable to LC, and the number of YLGs if death due to LC was averted by LCS. Results: In Brazil, the eligible population for LCS was 27 280 920 ever-smokers aged 50 to 80 years (13 387 552 female [49.1%]; 13 249 531 [48.6%] aged 50-60 years; 394 994 Asian or Indigenous [1.4%]; 3 111 676 Black [11.4%]; 10 942 640 Pardo [40.1%]; 12 830 904 White [47.0%]; 12 428 536 [45.6%] with an incomplete middle school education; and 12 860 132 [47.1%] living in the Southeast region); 5 144 322 individuals met the USPSTF 2013 criteria for LCS (2 090 636 female [40.6%]; 2 290 219 [44.5%] aged 61-70 years; 66 430 Asian or Indigenous [1.3%]; 491 527 Black [9.6%]; 2 073 836 Pardo [40.3%]; 2 512 529 [48.8%] White; 2 436 221 [47.4%] with an incomplete middle school education; and 2 577 300 [50.1%] living in the Southeast region), and 8 380 279 individuals met the USPSTF 2021 LCS criteria (3 507 760 female [41.9%]; 4 352 740 [51.9%] aged 50-60 years; 119 925 Asian or Indigenous [1.4%]; 839 171 Black [10.0%]; 3 330 497 Pardo [39.7%]; 4 090 687 [48.8%] White; 4 022 784 [48.0%] with an incomplete middle school education; and 4 162 070 [49.7%] living in the Southeast region). The number needed to screen to prevent 1 death was 177 individuals according to the USPSTF 2013 criteria and 242 individuals according to the USPSTF 2021 criteria. The YLG was 23 for all ever-smokers, 19 for the USPSTF 2013 criteria, and 21 for the USPSTF 2021 criteria. Being Black, having less than a high school education, and living in the North and Northeast regions were associated with increased 5-year risk of LC death. Conclusions and Relevance: In this comparative effectiveness study, USPSTF 2021 criteria were better than USPSTF 2013 in reducing disparities in LC death rates. Nonetheless, the risk of LC death remained unequal, and these results underscore the importance of identifying an appropriate approach for high-risk populations for LCS, considering the local epidemiological context.

Factors associated with late-stage diagnosis and overall survival for lung cancer: An analysis of patients treated in a Brazilian hospital and a US-hospital from 2009 to 2019.

BACKGROUND: Lung cancer is a major public health problem due to its high incidence and mortality rates worldwide. Histology, socioeconomic conditions, access, quality of healthcare, and regional aspects are associated with lung cancer stages at diagnosis and survival outcomes. This paper aims to examine and contrast the factors associated with late-stage diagnosis of lung cancer and overall survival rates in two different settings: a Brazilian hospital and a US hospital, spanning from 2009 to 2019. METHODS: This is a retrospective cohort study of the incidence of lung cancer cases at the institution's cancer registry from a Brazilian and a US-based cohort. Descriptive analyses are presented using either the mean and standard deviation or the median and interquartile interval. Frequency is used to present categorical variables. Factors associated with late-stage lung cancer diagnosis were identified through bivariate and multivariable forward stepwise logistic regression. One-year overall survival and its associated factors were identified by Kaplan-Meier curves and Cox's proportional hazards model. RESULTS: Between January 2009 and December 2019, a total of 5286 individuals were diagnosed with LC in the Brazilian cohort, and out of these cases, 85.6% were diagnosed with late-stage disease. The US-cohort consisted of 3594 individuals, of whom 60.3% were diagnosed with late-stage disease in lung cancer. The one-year overall survival was 8.6 months for the US cohort and 6.4 months for the Brazilian cohort. In both cohorts, late-stage diagnosis emerged as the most significant factor influencing overall survival. However, the factors associated with late-stage diagnosis differed between the US and Brazilian cohorts. In the Brazilian cohort, being male and belonging to black or brown ethnic groups, along with having a lower education level, were linked to late-stage diagnosis. On the other hand, in the US-based cohort, the factors related to late-stage diagnosis were being male, having been diagnosed before 2015, and possessing private insurance coverage. CONCLUSION: Late-stage diagnosis was associated with the worst survival in both the US and Brazilian cohorts. This study provides valuable information on inequities and barriers to access for lung patients with cancer from upper-middle-income and high-income countries.

Spatial analysis and factors associated with transcatheter aortic valve implantation in Portugal: a retrospective analysis from 2015 to 2017.

OBJECTIVES: To identify the factors associated with transcatheter aortic valve implantation (TAVI) use of TAVI in inpatients with aortic stenosis (AS) in Portugal and its geographical distribution. METHODS: A quantitative, observational and retrospective study using the Portuguese National Health Service inpatient discharge database from 2015 to 2017. Surgical aortic valve replacement (SAVR) and TAVI procedures were selected using the International Classification of Diseases. First, we mapped the yearly age-standardised rate for each procedure using QGIS. Then, we performed χ2 tests, independent t-tests and logistic regressions to study the factors associated with TAVI use. RESULTS: From 2015 to 2017, 8398 hospitalisations were selected, 88.5% SAVR and 11.5% TAVI. From 2015 to 2017, SAVR use increased in the Northern region and decreased in the Lisbon region, while the opposite was observed for TAVI. TAVI was performed among the most complex (p<0.001) and older patients (the mean (SD) age for SAVR was 70 (±11) years old and 81 (±7) years old for TAVI, p<0.001). The results for the logistic regressions showed that, more recent hospitalisations, being older, living in the Lisbon region and having a higher Charlson Comorbidity Index was associated with an increased likelihood of undergoing TAVI (p<0.001). CONCLUSIONS: TAVI increased over the years. TAVI is more often performed in more severe patients as an alternative to SAVR with similar discharge outcomes. These results suggest the existence of geographic disparities in the availability and access to healthcare services and technologies.

Association Between the Modified Frailty Index and Outcomes Following Lobectomy.

INTRODUCTION: Elective thoracic surgery is safe in well-selected elderly patients. The association of frailty with postoperative morbidity in elective-lobectomy patients is understudied. We examined frailty as defined by abbreviated modified frailty index (mFI-5), mFI-11 in the thoracic surgery population, and the correlation between frailty and postoperative complications. METHODS: We studied outcomes of patients in two cohorts, 2010-2012 and 2013-2019, from the National Surgical Quality Improvement Program (NSQIP) database and used multivariable logistic regression models to predict all postoperative morbidity, mortality, and major morbidity. The mFI-5 could be calculated for all subjects (both 2010-2012, and 2013-2019); the mFI-11 could only be calculated for the 2010-2012 cohort. Patient frailty was defined as mFI≥3 (with either index). We used odds ratios (ORs) to examine associations of preoperative characteristics with postoperative complications and C-statistics to assess overall predictive power. RESULTS: Complications were less prevalent in the 2013-2019 cohort (17.9% versus 19.5%, P = 0.008). Open lobectomies were more common in the 2010-2012 cohort (53.9% versus 34.6%) and were strongly associated with postoperative morbidity and mortality (ORs >1.5) in both cohorts. Each frailty measure was associated with morbidity and mortality (ORs >1.4) after adjusting for other significant preoperative factors. Models on the 2010-2012 cohort had nearly identical C-statistics using the mFI-11 versus mFI-5 frailty indices (0.6142 versus 0.6139; P > 0.8). CONCLUSIONS: Frailty, as captured in the mFI-5, is a significant associated factor of postoperative morbidity and mortality following elective lobectomies. As a modifiable risk factor, frailty should be considered in surgical decision-making and when counseling patients regarding perioperative risks.

Desempenho das Unidades Básicas de Saúde e uso do Programa Farmácia Popular / Performance of Basic Health Unitsand use ofthe Popular PharmacyProgram

Resumo Introdução O Brasil conta com dois programas de financiamento governamental para a provisão de medicamentos, o Programa Farmácia Popular do Brasil (PFPB) e a provisão em Unidades do Sistema Único de Saúde, ambos possuindo itens em comum. Objetivo Explorar a relação entre o uso do PFPB por hipertensos e diabéticos com fatores relacionados ao atendimento nas Unidades Básicas de Saúde, à estrutura da farmácia destas Unidades e à disponibilidade dos anti-hipertensivos e antidiabéticos comuns ao PFPB e ao SUS em municípios brasileiros de médio e grande porte populacional. Método Delineamento ecológico transversal utilizando dados secundários do PFPB e do Programa Nacional de Melhoria do Acesso e Qualidade na Atenção Básica (PMAQ-AB), com dados referentes ao ano de 2012. Resultados Municípios de médio porte apresentaram uma proporção de Unidades de Saúde com disponibilidade de anti-hipertensivos e antidiabéticos superior aos de grande porte. A maioria dos respondentes do PMAQ-AB relataram disponibilidade dos anti-hipertensivos e antidiabéticos nos serviços públicos. A análise multivariada mostrou que o uso da Farmácia Popular pela população está mais relacionado às situações emergenciais e ocasionais. Conclusão Na ausência do SUS, o PFPB supre a necessidade da população para obter medicamentos, evidenciando o seu importante papel para a continuidade do tratamento de muitos indivíduos com hipertensão e diabetes.

Abstract Background Brazil has two government-funded drug supply programs, the Popular Pharmacy Program of Brazil (PFPB), and the provision in Unified Health System (SUS) units, which have items in common. Objective To explore the relationship between the use of PFPB by hypertensive and diabetic patients and factors related to care in basic health units, the pharmacy structure of units, and the availability of antihypertensive and antidiabetic agents common to PFPB and SUS in Brazilian municipalities of medium and large population sizes. Method A cross-sectional ecological study was carried out using secondary data from PFPB and the National Program for Improving Access and Quality in Primary Care (PMAQ-AB) for 2012. Results Municipalities of medium population showed a greater proportion of health units with antihypertensive and antidiabetic availability than those of large size. Most respondents at PMAQ-AB affirmed that hypertension and diabetes medications are available in public health services. The multivariate analysis showed that the use of Popular Pharmacy by the population is more related to emergency and occasional situations. Conclusion PFPB supplies the need for the population to obtain medications in the absence of SUS, evidencing an important role in the continuity of drug treatment for many individuals suffering from hypertension and diabetes.

Registros Hospitalares de Câncer: Proposta Metodológica para Correção do Estadiamento de Câncer de Pulmão / Hospital-Based Cancer Registry: Methodological Proposal for Correction of Lung Cancer Staging / Registros Hospitalarios de Cáncer: Propuesta Metodológica para la Corrección de la Estadificación del Cáncer de Pulmón

Introdução: Um grande desafio para a utilização de registros e bases de dados secundárias é a qualidade do registro e o percentual de perdas em variáveis estratégicas e necessárias à plena utilização do banco. Objetivo: Propor um método de correção para a variável de estadiamento no âmbito dos Registros Hospitalares de Câncer (RHC), a fim de aprimorar sua completude e qualidade. Método: Estudo descritivo, abrangendo as Unidades da Federação, utilizando-se como fonte de informação o RHC, de janeiro de 2013 a dezembro de 2019. O câncer de pulmão foi escolhido como caso para a correção do banco, em razão da sua alta taxa de mortalidade no Brasil e no mundo. As análises foram realizadas com o software de análises estatísticas SAS Studio e a base de dados organizada em Excel. Resultados: O total de casos registrados no RHC foi de 86.026, e a variável de interesse, o estadiamento, teve um total de 32,0% de perda. Ao final de todas as etapas de correção, a perda foi de 9,8%, correspondendo a 22,2% de recuperação. Conclusão: A metodologia proposta representa um avanço na correção do banco do RHC, possibilitando a utilização dos dados de base secundária, com melhor representatividade das diferentes Regiões do país, sobre o tratamento de câncer de pulmão, com possibilidade de expansão de seu uso para outras topografias

Introduction: A major challenge to utilize the registries and secondary databases is the quality of the data and the percentage of losses in strategic and necessary variables for better effectiveness of the database. Objective: To propose a correction method for the cancer staging variable of the HospitalBased Cancer Registry (HBCR), to improve its completeness and quality. Method: HBCR-based descriptive analysis covering Brazil's Federation Units from January 2013 to December 2019. Due to its high mortality in Brazil and worldwide, lung cancer was selected as case for database correction. The analyzes were performed with the software SAS Studio for statistical analyzes and the data were organized in Excel. Results: The total number of cases registered at the HBCR was 86,026, and 32% the variable of interest, staging, were missed. At the end of the correction process, the missed data reached 9.8%, corresponding to a recovery of 22.2%. Conclusion: The proposed methodology is an advance for the correction of the HBCR database on the treatment of lung cancer, allowing a more extensive use, with better representativeness of different country regions, and potential utilization in other topographies

Introducción: Un gran desafío para el uso de registros y bases de datos secundarias es la calidad del registro en sí, el porcentaje de pérdidas en variables estratégicas y necesarias para el pleno uso de la base de datos. Objetivo: Proponer un método de corrección de la variable estadificación en el ámbito de los Registros Hospitalarios de Cáncer (RHC), con el fin de mejorar su exhaustividad y calidad. Método: Análisis descriptivo, abarcando las Unidades de la Federación. Se utilizó el RHC como fuente de información, de enero de 2013 a diciembre de 2019. El cáncer de pulmón fue elegido como caso para la corrección de la base de datos, debido a su alta tasa de mortalidad en el Brasil y en el mundo. Los análisis se realizaron con el software de análisis estadístico SAS Studio y los datos se organizaron en Excel. Resultados: El total de casos registrados en el RHC fue de 86.026, y la variable de interés, la estadificación, tuvo una pérdida total del 32,0% Al final de todas las etapas esta fue de 9,8%, es decir el 22,2% de recuperación. Conclusión: La metodología propuesta representa un avance en la corrección del RHC, permitiendo una mejor utilización de la base de datos, con una mejor representatividad de las diferentes regiones del país, sobre el tratamiento del cáncer de pulmón, con la posibilidad de expandir su uso a otras topografías

Caracterização da atenção ao paciente com diabetes na atenção primária a partir do PMAQ-AB / Characterization of primary health care for patients with diabetes based on the PMAQ-AB

Resumo Este artigo tem o objetivo de apresentar uma proposta de compatibilização dos instrumentos utilizados nos três ciclos do PMAQ-AB e analisar as informações de acesso, cobertura, estrutura, organização e oferta de serviços na APS relacionadas ao cuidado para DM no Brasil, segundo regiões, a partir da perspectiva das equipes de saúde da família e dos usuários. Foi realizada uma análise do grau de compatibilidade das questões do PMAQ-AB (2012, 2014 e 2017). Para análise da evolução temporal dos componentes realizou-se teste de diferença de proporção. Calculou-se a diferença percentual entre a perspectiva das Equipes e dos Usuários, por ano analisado, para Brasil. Em geral, houve melhora da qualidade do cuidado e realização de exames, com exceção do pé diabético. Foram encontrados resultados piores para o Norte em relação às demais regiões. Apesar da melhora estrutural e na qualidade da atenção reportada pelas equipes, foram evidenciadas lacunas significativas na qualidade do cuidado ao paciente com DM no SUS. No cenário de investimento escasso e crescente prevalência de DM, os obstáculos tornam-se cada vez mais desafiadores e, por isso, o monitoramento e avaliação da qualidade dos serviços prestados são tarefas precípuas do SUS.

Abstract This article aims to present a proposal for making the instruments used in the three cycles of the PMAQ-AB compatible and to analyze the information on access, coverage, structure, organization and provision of services in PHC related to care for DM in Brazil, according to regions, from the perspective of family health professionals and users. We performed an analysis of the degree of compatibility of the PMAQ-AB questions (2012, 2014 and 2017). To analyze the temporal evolution of the components, we performed a proportion difference test. We calculated the percentage difference between the perspective of professionals and users, per year analyzed, for Brazil. In general, there was an improvement in the quality of care and examinations, except for the diabetic foot. Worse results were found for the North region in relation to the other regions. Despite the structural improvement and the quality of care reported by professionals, there are significant gaps in the quality of care for patients with DM in the SUS. In the scenario of scarce investment added to the growing prevalence of DM, obstacles become progressively more challenging. Therefore, monitoring and evaluating the quality of services provided are essential tasks of the Brazilian Health System.

Characterization of primary health care for patients with diabetes based on the PMAQ-AB. / Caracterização da atenção ao paciente com diabetes na atenção primária a partir do PMAQ-AB.

This article aims to present a proposal for making the instruments used in the three cycles of the PMAQ-AB compatible and to analyze the information on access, coverage, structure, organization and provision of services in PHC related to care for DM in Brazil, according to regions, from the perspective of family health professionals and users. We performed an analysis of the degree of compatibility of the PMAQ-AB questions (2012, 2014 and 2017). To analyze the temporal evolution of the components, we performed a proportion difference test. We calculated the percentage difference between the perspective of professionals and users, per year analyzed, for Brazil. In general, there was an improvement in the quality of care and examinations, except for the diabetic foot. Worse results were found for the North region in relation to the other regions. Despite the structural improvement and the quality of care reported by professionals, there are significant gaps in the quality of care for patients with DM in the SUS. In the scenario of scarce investment added to the growing prevalence of DM, obstacles become progressively more challenging. Therefore, monitoring and evaluating the quality of services provided are essential tasks of the Brazilian Health System.

Este artigo tem o objetivo de apresentar uma proposta de compatibilização dos instrumentos utilizados nos três ciclos do PMAQ-AB e analisar as informações de acesso, cobertura, estrutura, organização e oferta de serviços na APS relacionadas ao cuidado para DM no Brasil, segundo regiões, a partir da perspectiva das equipes de saúde da família e dos usuários. Foi realizada uma análise do grau de compatibilidade das questões do PMAQ-AB (2012, 2014 e 2017). Para análise da evolução temporal dos componentes realizou-se teste de diferença de proporção. Calculou-se a diferença percentual entre a perspectiva das Equipes e dos Usuários, por ano analisado, para Brasil. Em geral, houve melhora da qualidade do cuidado e realização de exames, com exceção do pé diabético. Foram encontrados resultados piores para o Norte em relação às demais regiões. Apesar da melhora estrutural e na qualidade da atenção reportada pelas equipes, foram evidenciadas lacunas significativas na qualidade do cuidado ao paciente com DM no SUS. No cenário de investimento escasso e crescente prevalência de DM, os obstáculos tornam-se cada vez mais desafiadores e, por isso, o monitoramento e avaliação da qualidade dos serviços prestados são tarefas precípuas do SUS.

Effect of municipal and state regulation on access and outcomes for cervical cancer patients in Rio de Janeiro, Brazil: An interrupted time series analysis.

BACKGROUND: Cervical cancer (CC) is one of Brazil's most prevalent neoplasms, and organizing health care flows that guarantee adequate and timely referral is a challenge. This paper analyzes the effect of municipal and state regulation on access and outcomes for CC patients treated in Rio de Janeiro. METHODS: Retrospective, quasi-experimental study, applying interrupted time series, using data from Cancer Registry from January-2012 to December-2017. We analyzed the implementation of the municipal (August-2013) and state (June-2015) regulation systems for the treatment of CC. The primary outcomes were 1. Time from diagnosis to the first Specialist Visit (TSV); 2. Time from a specialist visit to Treatment Initiation (TSV-TTI); 3. Time from diagnosis to treatment initiation (DTTI); 4. Percentage of patients with adequate Time to Treatment Initiation (PATTI); 5. Percentage of patients with a positive outcome (PPO). RESULTS: were included 4119 women. 71.04 % were between 30 and 59 years old, 55.57 % were black or brown, and 50.52 % had completed elementary school. The monthly average TSV was 43 days in 2012. After the first intervention, TSV increased by seven days, with a decreasing trend of 1 day per month until December-2017. Similarly, after June-2015, DTTI increased to 63 days, decreasing by one day per month until December-2017. After both interventions, there was an increase of 11.98 % in PATTI, with an increasing monthly trend of 0.18 %. PPO remained stable throughout the analyzed period. CONCLUSION: the results suggest that regulation organized access flow for specialized care. However, other relevant issues must be addressed, such as an internal backlog at the institutions, which compromises a timely start of treatment. POLICY SUMMARY: To improve access to the diagnosis and treatment of CC in its early stages, it is necessary to invest in health policies to adjust the supply to the required demand and thus reduce mortality from this pathology.

Impact of the National Lung Screening Trial (NLST) publication and Medicare Lung cancer screening payment on lung cancer incidence rates: An interrupted time series analysis.

INTRODUCTION: Explore the impact of the Lung Cancer Screening Trial (NLST-September-2011) and the Medicare approval for CT-screening (CT-LCS-AP-February-2015) on lung cancer incidence rates, mortality, and the percentage of early-stage lung cancer diagnosis (ESLCD-T1-T2N0M0). METHODS: Retrospective interrupted time series analysis using SEER-18 database. All individuals with lung cancer (LC) diagnosis from 2006 to 2016 were included. The effect of NLST and CT-AP-2015 on the monthly percentage of early-stage ESLCD was the primary outcome, additionally LC incidence and mortality rates were calculated. The analysis was performed by age, sex, race, marital status, insurance status, and household income. Bivariate and multivariate models were used to identify predictors of ESLCD. RESULTS: The study cohort was composed by 388,207 individuals, 69 years old in average, 46.6 % female, and 81.1 % white. LC incidence and mortality rates declined from 2006 to 2016 without association with NLST-September-2011 and CT-LCS-AP-February-2015. The percentage of ESLCD increased over time for all groups. Overall rates of ESLCD started at 18 % in January-2006 and increased to 25 % by December-2016. The intervention NLST-2011 did not show an impact in the ESLCD while the CT-AP-2015 showed a significant impact in the ESLCD trend (p < 0.001). ESLCD was associated with female, white, insurance, and household incomes above median. Medicare expansion was a significant factor for insured group, married patients and those from households under the median income level. CONCLUSION: Medicare approval for CT screening was found to have a statistically significant effect on the diagnosis of early-stage lung cancer and neither NLST-September-2011 nor CT-AP-2015-February-2015 impacted the incidence nor mortality rates. POLICY SUMMARY: To improve early-stage lung cancer diagnosis, it is vital to invest in health policies to increase Lung Cancer Screening implementation and to reduce disparities in access to diagnosis. Furthermore, policies that facilitate access to diagnosis and treatment are crucial to reduce lung cancer mortality.

Supply and demand of procedures related to diabetes mellitus and its complications in Brazil. / Oferta e demanda de procedimentos atribuíveis ao diabetes mellitus e suas complicações no Brasil.

This article aims to present a methodology for monitoring the procedures recommended in the care protocol for diabetic patients, based on the indicator of the ratio between supply and demand for exams, according to Brazil, macro-regions, federative units (FUs), and municipalities. The prevalence of diabetes mellitus (DM) and its complications were estimated using a multinomial model. The offer of DM procedures was obtained from the Ambulatory Information System (SIA/SUS) and the demand from the number of tests defined in the protocol as necessary per year, according to disease risk categories. Based on this, the supply-demand ratio indicator was created. The innovation here consists of analyzing the demand for diabetic care according to established parameters and the supply of health services together. The connection between the recommended treatment protocol and the existence of the service offered concerning the demand for care based on the prevalence of the disease provides a key monitoring tool. And, when analyzed together with the indicator of the ratio between supply and demand for procedures, these measures become a proxy for the quality of prevention and care for patients with the disease.

Este artigo tem como objetivo apresentar uma metodologia de monitoramento dos procedimentos preconizados no protocolo de atenção ao paciente diabético a partir do indicador de razão entre a oferta e a demanda de exames, segundo nível nacional, macrorregiões, UF e municípios. A prevalência de diabetes mellitus (DM) e suas complicações foi estimada a partir de modelo multinomial. A oferta de procedimentos para DM foi obtida a partir do Sistema de Informações Ambulatoriais (SIA/SUS) e a demanda a partir do número de exames definidos no protocolo como necessários por ano, segundo categorias de risco da doença. A partir disso foi criado o indicador de razão entre oferta e demanda. A inovação que ora apresentamos consiste em analisar conjuntamente a demanda por cuidado ao diabético segundo parâmetros estabelecidos e a oferta de serviços de saúde. A conexão entre o protocolo de tratamento preconizado e a existência do serviço ofertado em relação da demanda de cuidado baseada na prevalência da doença disponibiliza uma ferramenta chave de monitoramento. E, quando analisado conjuntamente ao indicador de razão entre oferta e demanda de procedimentos, essas medidas tornam-se proxy da qualidade da prevenção e atenção ao portador da doença.

Oferta e demanda de procedimentos atribuíveis ao diabetes mellitus e suas complicações no Brasil / Supply and demand of procedures related to diabetes mellitus and its complications in Brazil

Resumo Este artigo tem como objetivo apresentar uma metodologia de monitoramento dos procedimentos preconizados no protocolo de atenção ao paciente diabético a partir do indicador de razão entre a oferta e a demanda de exames, segundo nível nacional, macrorregiões, UF e municípios. A prevalência de diabetes mellitus (DM) e suas complicações foi estimada a partir de modelo multinomial. A oferta de procedimentos para DM foi obtida a partir do Sistema de Informações Ambulatoriais (SIA/SUS) e a demanda a partir do número de exames definidos no protocolo como necessários por ano, segundo categorias de risco da doença. A partir disso foi criado o indicador de razão entre oferta e demanda. A inovação que ora apresentamos consiste em analisar conjuntamente a demanda por cuidado ao diabético segundo parâmetros estabelecidos e a oferta de serviços de saúde. A conexão entre o protocolo de tratamento preconizado e a existência do serviço ofertado em relação da demanda de cuidado baseada na prevalência da doença disponibiliza uma ferramenta chave de monitoramento. E, quando analisado conjuntamente ao indicador de razão entre oferta e demanda de procedimentos, essas medidas tornam-se proxy da qualidade da prevenção e atenção ao portador da doença.

Abstract This article aims to present a methodology for monitoring the procedures recommended in the care protocol for diabetic patients, based on the indicator of the ratio between supply and demand for exams, according to Brazil, macro-regions, federative units (FUs), and municipalities. The prevalence of diabetes mellitus (DM) and its complications were estimated using a multinomial model. The offer of DM procedures was obtained from the Ambulatory Information System (SIA/SUS) and the demand from the number of tests defined in the protocol as necessary per year, according to disease risk categories. Based on this, the supply-demand ratio indicator was created. The innovation here consists of analyzing the demand for diabetic care according to established parameters and the supply of health services together. The connection between the recommended treatment protocol and the existence of the service offered concerning the demand for care based on the prevalence of the disease provides a key monitoring tool. And, when analyzed together with the indicator of the ratio between supply and demand for procedures, these measures become a proxy for the quality of prevention and care for patients with the disease.

Use of In-Situ Simulation Based Clinical Systems Test of Thoracic Robotic Surgery Emergencies.

INTRODUCTION: With the advancement of robotic surgery, some thoracic surgeons have been slow to adopt to this new operative approach, in part because they are un-scrubbed and away from the patient while operating. Aiming to allay surgeon concerns of intra-operative emergencies, an insitu simulation-based clinical system's test (SbCST) can be completed to test the current clinical system, and to practice low-frequency, high-stakes clinical scenarios with the entire operating room (OR) team. METHODS: Six different OR teams completed an insitu SbCST of an intra-operative pulmonary artery injury during a robot-assisted thoracic surgery at a single tertiary care center. The OR team consisted of an attending thoracic surgeon, surgery resident, anesthesia attending, anesthesia resident, circulating nurse, and a scrub technician. This test was conducted with an entire OR team along with study observers and simulation center staff. Outcomes included the identified latent safety threats (LSTs) and possible solutions for each LST, culminating in a complete failure mode and effects analysis (FMEA). A Risk Priority Number (RPN) was determined for each LST identified. Pre- and post-simulation surveys using Likert scales were also collected. RESULTS: The six FMEAs identified 28 potential LSTs in four categories. Of these 28 LSTs, nine were considered high priority based on their Risk Priority Number (RPN) with seven of the nine being repeated multiple times. Pre- and post-simulation survey responses were similar, with the majority of participants (94%) agreeing that high fidelity simulation of intra-operative emergencies is helpful and provides an opportunity to train for high-stakes, low-frequency events. After completing the SbCST, more participants felt confident that they knew their role during an intra-operative emergency than their pre-simulation survey responses. All participants agreed that simulation is an important part of continuing education and is helpful for learning skills that are infrequently used. Following the SbCST, more participants agreed that they knew how to safely undock the da Vinci robot during an emergency. CONCLUSIONS: SbCSTs provide an opportunity to test the current clinical system with a low-frequency, high-stakes event and allow medical personnels to practice their skills and teamwork. By completing multiple SbCSTs, we were able to identify multiple LSTs within different OR teams, allowing for a broader review of the current clinical systems in place. The use of these SbCSTs in conjunction with debriefing sessions and FMEA completion allows for the most significant potential improvement of the current system. This study shows that SbCST with FMEA completion can be used to test current systems and create better systems for patient safety.

Factors associated with diagnosis of stages I and II lung cancer: a multivariate analysis.

OBJECTIVE: To present the overall survival rate for lung cancer and identify the factors associated with early diagnosis of stage I and II lung cancer. METHODS: This is a retrospective cohort study including individuals diagnosed with lung cancer, from January 2009 to December 2017, according to the cancer registry at UMass Memorial Medical Center. Five-year overall survival and its associated factors were identified by Kaplan-Meier curves and Cox's proportional hazards model. Factors associated with diagnosing clinical stage I and II lung cancer were identified by bivariate and multivariate backward stepwise logistic regression (Log-likelihood ratio (LR)) at 95% confidence interval (CI). RESULTS: The study was conducted with data on 2730 individuals aged 67.9 years on average, 51.5% of whom female, 92.3% white, and 6.6% never smoked. Five-year overall survival was 21%. Individuals diagnosed with early-stage disease had a 43% five-year survival rate compared to 8% for those diagnosed at late stages. Stage at diagnosis was the main factor associated with overall survival [HR = 4.08 (95%CI: 3.62-4.59)]. Factors associated with early diagnosis included patients older than 68 years [OR = 1.23 (95%CI: 1.04-1.45)], of the female gender [OR = 1.47 (95%CI: 1.24-1.73)], white [OR = 1.63 (95%CI: 1.16-2.30)], and never-smokers [OR = 1.37 (95%CI: 1.01-1.86)]; as well as tumors affecting the upper lobe [OR = 1.46 (95%CI: 1.24-1.73)]; adenocarcinoma [OR = 1.43 (95%CI: 1.21-1.69)]; and diagnosis after 2014 [OR = 1.61 (95%CI: 1.37-1.90)]. CONCLUSIONS: Stage at diagnosis was the most decisive predictor for survival. Non-white and male individuals were more likely to be diagnosed at a late stage. Thus, promoting lung cancer early diagnosis by improving access to health care is vital to enhance overall survival for individuals with lung cancer.