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OBJECTIVES: To develop and validate approaches for mapping Oswestry Disability Index responses to 3-level version of EQ-5D utility values and to evaluate the impact of using mapped utility values on cost-utility results compared with published regression models. METHODS: Three response mapping approaches were developed in a random sample of 70% of 18 692 patients with low back pain: nonparametric approach (Non-p), nonparametric approach excluding logical inconsistencies (Non-peLI), and ordinal logistic regression (OLR). Performance was assessed in the remaining 30% using R-square (R2), root mean square error (RMSE), and mean absolute error (MAE). To evaluate whether MAEs and their 95% limits of agreement (LA) were clinically relevant, a minimally clinically important difference of 0.074 was used. Probabilities of cost-effectiveness estimated using observed and mapped utility values were compared in 2 economic evaluations. RESULTS: The Non-p performed the best (R2 = 0.43; RMSE = 0.22; MAE = 0.03; 95% LA = -0.40 to 0.47) compared with the Non-peLI (R2 = 0.07; RMSE = 0.29; MAE = -0.15; 95% LA = -0.63 to 0.34) and OLR (R2 = 0.22; RMSE = 0.26; MAE = 0.02; 95% LA = -0.49 to 0.53). MAEs were lower than the minimally clinically important difference for the Non-p and OLR but not for the Non-peLI. Differences in probabilities of cost-effectiveness ranged from 1% to 4% (Non-p), 0.1% to 9% (Non-peLI), and 0.1% to 20% (OLR). CONCLUSIONS: Results suggest that the developed response mapping approaches are not valid for estimating individual patients' 3-level version of EQ-5D utility values, and-depending on the approach-may considerably affect cost-utility results. The developed approaches did not perform better than previously published regression-based models and are therefore not recommended for use in economic evaluations.
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Dor Lombar , Qualidade de Vida , Humanos , Inquéritos e Questionários , Dor Lombar/diagnóstico , Modelos Logísticos , Análise Custo-Benefício , AlgoritmosRESUMO
OBJECTIVES: Hospital admission in older adults is associated with unwanted outcomes such as readmission, institutionalization, and functional decline. To reduce these outcomes, the Netherlands introduced an alternative to hospital-based care: the Acute Geriatric Community Hospital (AGCH). The AGCH is an acute care unit situated outside of a hospital focusing on early rehabilitation and comprehensive geriatric assessment. The objective of this study was to evaluate if AGCH care is associated with decreasing unplanned readmissions or death compared with hospital-based care. DESIGN: Prospective cohort study controlled with a historic cohort. SETTING AND PARTICIPANTS: A (sub)acute care unit (AGCH) and 6 hospitals in the Netherlands; participants were acutely ill older adults. METHODS: We used inverse propensity score weighting to account for baseline differences. The primary outcome was 90-day readmission or death. Secondary outcomes included 30-day readmission or death, time to death, admission to long-term residential care, occurrence of falls and functioning over time. Generalized logistic regression models and multilevel regression analyses were used to estimate effects. RESULTS: AGCH patients (n = 206) had lower 90-day readmission or death rates [odds ratio (OR) 0.39, 95% CI 0.23-0.67] compared to patients treated in hospital (n = 401). AGCH patients had a lower risk of 90-day readmission (OR 0.38, 95% CI 0.21-0.67) but did not differ on all-cause mortality (OR 0.89, 95% CI 0.44-1.79) compared with the hospital control group. AGCH patients had lower 30-day readmission or death rates. Secondary outcomes did not differ. CONCLUSIONS AND IMPLICATIONS: AGCH patients had lower rates of readmission and/or death than patients treated in a hospital. Our results support further research on the implementation and cost-effectiveness of AGCH in the Netherlands and other countries seeking alternatives to hospital-based care.
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Hospitais Comunitários , Alta do Paciente , Humanos , Idoso , Estudos Prospectivos , Países Baixos , Hospitalização , Readmissão do PacienteRESUMO
INTRODUCTION: The EQ-5D-Y-3L is a generic measure of health-related quality of life in children and adolescents. Although the Brazilian-Portuguese EQ-5D-Y-3L version is available, there is no value set for it, hampering its use in economic evaluations. This study aimed to elicit a Brazilian EQ-5D-Y-3L value set based on preferences of the general adult population. METHODS: Two independent samples of adults participated in an online discrete choice experiment (DCE) survey and a composite time trade-off (cTTO) face-to-face interview. The framing was "considering your views for a 10-year-old child". DCE data were analyzed using a mixed-logit model. The 243 DCE predicted values were mapped into the observed 28 cTTO values using linear and non-linear mapping approaches with and without intercept. Mapping approaches' performance was assessed to estimate the most valid method to rescale DCE predicted values using the model fit (R2), Akaike Information Criteria (AIC), root mean squared error (RMSE), and mean absolute error (MAE). RESULTS: A representative sample of 1376 Brazilian adults participated (DCE, 1152; cTTO, 211). The linear mapping without intercept (R2 = 96%; AIC, - 44; RMSE, 0.0803; MAE, - 0.0479) outperformed the non-linear without intercept (R2 = 98%; AIC, - 63; RMSE, 0.1385; MAE, - 0.1320). Utilities ranged from 1 (full health) to - 0.0059 (the worst health state). Highest weights were assigned to having pain or discomfort (pain/discomfort), followed by walking about (mobility), looking after myself (self-care), doing usual activities (usual activities), and feeling worried, sad, or unhappy (anxiety/depression). CONCLUSION: This study elicited the Brazilian EQ-5D-Y-3L value set using a mixed-logit DCE model with a power parameter based on a linear mapping without intercept, which can be used to estimate the quality-adjusted life-years for economic evaluations of health technologies targeting the Brazilian youth population.
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Qualidade de Vida , Humanos , Brasil , Feminino , Masculino , Adulto , Inquéritos e Questionários , Adolescente , Comportamento de Escolha , Pessoa de Meia-Idade , Adulto Jovem , Criança , Nível de SaúdeRESUMO
BACKGROUND: A Dutch nationwide prospective cohort study was initiated to investigate recovery trajectories of people recovering from coronavirus disease 2019 (COVID-19) and costs of treatment by primary care allied health professionals. OBJECTIVES: The study described recovery trajectories over a period of 12 months and associated baseline characteristics of participants recovering from COVID-19 who visited a primary care allied health professional. It also aimed to provide insight into the associated healthcare and societal costs. METHODS: Participants completed participant-reported standardized outcomes on participation, health-related quality of life, fatigue, physical functioning, and costs at baseline (ie, start of the treatment), 3, 6, 9 and 12 months. RESULTS: A total of 1451 participants (64 % women, 76 % mild/moderate severity) with a mean (SD) age of 49 (12) years were included. Linear mixed models showed significant and clinically relevant improvements over time in all outcome measures between baseline and 12 months. Between 6 and 12 months, we found significant but not clinically relevant improvements in most outcome measures. Having a worse baseline score was the only baseline factor that was consistently associated with greater improvement over time on that outcome. Total allied healthcare costs (mean 1921; SEM 48) made up about 3% of total societal costs (mean 64,584; SEM 3149) for the average participant in the cohort. CONCLUSIONS: The health status of participants recovering from COVID-19 who visited an allied health professional improved significantly over a 12-month follow-up period, but nearly the improvement occurred between baseline and 6 months. Most participants still reported severe impairments in their daily lives, and generated substantial societal costs. These issues, combined with the fact that baseline characteristics explained little of the variance in recovery over time, underscore the importance of continued attention for the management of people recovering from COVID-19. TRIAL REGISTRATION: clinicaltrials.gov (NCT04735744).
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PURPOSE: Inconsistent results have been found on the impact of using crosswalks versus EQ-5D value sets on reimbursement decisions. We sought to further investigate this issue in a simulation study. METHODS: Trial-based economic evaluation data were simulated for different conditions (depression, low back pain, osteoarthritis, cancer), severity levels (mild, moderate, severe), and effect sizes (small, medium, large). For all 36 scenarios, utilities were calculated using 3L and 5L value sets and crosswalks (3L to 5L and 5L to 3L crosswalks) for the Netherlands, the United States, and Japan. Utilities, quality-adjusted life years (QALYs), incremental QALYs, incremental cost-effectiveness ratios (ICERs), and probabilities of cost-effectiveness (pCE) obtained from values sets and crosswalks were compared. RESULTS: Differences between value sets and crosswalks ranged from -0.33 to 0.13 for utilities, from -0.18 to 0.13 for QALYs, and from -0.01 to 0.08 for incremental QALYs, resulting in different ICERs. For small effect sizes, at a willingness-to-pay of 20,000/QALY, the largest pCE difference was found for moderate cancer between the Japanese 5L value set and 5L to 3L crosswalk (difference = 0.63). For medium effect sizes, the largest difference was found for mild cancer between the Japanese 3L value set and 3L to 5L crosswalk (difference = 0.06). For large effect sizes, the largest difference was found for mild osteoarthritis between the Japanese 3L value set and 3L to 5L crosswalk (difference = 0.08). CONCLUSION: The use of crosswalks instead of EQ-5D value sets can impact cost-utility outcomes to such an extent that this may influence reimbursement decisions.
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Neoplasias , Osteoartrite , Humanos , Nível de Saúde , Qualidade de Vida , Inquéritos e Questionários , Psicometria , Reprodutibilidade dos TestesRESUMO
OBJECTIVE: Information on the pregnancy rate after successive in-vitro fertilization (IVF) cycles and their associated costs is relevant for couples undergoing assisted reproduction treatments (ARTs). This study, therefore, sought to investigate the effectiveness and the cost-effectiveness of two ARTs, the minimal ovarian stimulation IVF (MS-IVF) compared to the conventional ovarian stimulation IVF (C-IVF) from the payer's perspective. METHODS: A 10-months follow-up prospective observational study was conducted in a sample of couples who sought ARTs in a private clinic in Southern Brazil. Women had to satisfy the Bologna Criteria and be older than 35 years. The effect outcome was pregnancy rate per initiated cycle. Medication costs were based on medical records. Costs and effect differences were estimated using seemingly unrelated regressions adjusted for the propensity score estimated based on women's characteristics. RESULTS: All 84 eligible women who agreed to participate received a total of 92 IVF cycles (MS-IVF, n=27[35 cycles]; C-IVF n=57[57 cycles]. The effect difference between MS-IVF and C-IVF was -5.1% (95%CI, -13.2 to 5.2). Medication costs of MS-IVF were significantly lower than C-IVF by -1260 (95%CI, -1401 to -1118). The probabilities of MS-IVF being cost-effective compared to C-IVF ranged from 1 to 0.76 for willingness-to-pay of 0 to 15,000 per established pregnancy, respectively. CONCLUSIONS: Even though there were no positive effect differences between groups, MS-IVF might be cost-effective compared to C-IVF from the payer's perspective due to its relatively large cost savings compared to C-IVF. However, further investigation is needed to confirm these findings in a larger sample.
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Coeficiente de Natalidade , Fertilização in vitro , Gravidez , Feminino , Humanos , Análise Custo-Benefício , Pontuação de Propensão , Indução da Ovulação , FertilizaçãoRESUMO
Trial-based economic evaluations are increasingly being conducted to support healthcare decision-making. When analysing trial-based economic evaluation data, different methodological challenges may be encountered, including (i) missing data, (ii) correlated costs and effects, (iii) baseline imbalances and (iv) skewness of costs and/or effects. Despite the broad range of methods available to account for these methodological challenges in effectiveness studies, they may not always be directly applicable in trial-based economic evaluations where costs and effects are analysed jointly, and more than one methodological challenge typically needs to be addressed simultaneously. The use of inappropriate methods can bias results and conclusions regarding the cost-effectiveness of healthcare interventions. Eventually, such low-quality evidence can hamper healthcare decision-making, which may in turn result in a waste of already scarce healthcare resources. Therefore, this tutorial aims to provide step-by-step guidance on how to combine appropriate statistical methods for handling the abovementioned methodological challenges using a ready-to-use R script. The theoretical background of the described methods is provided, and their application is illustrated using a simulated trial-based economic evaluation.
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INTRODUCTION: For the analysis of clinical effects, multiple imputation (MI) of missing data were shown to be unnecessary when using longitudinal linear mixed-models (LLM). It remains unclear whether this also applies to trial-based economic evaluations. Therefore, this study aimed to assess whether MI is required prior to LLM when analyzing longitudinal cost and effect data. METHODS: Two-thousand complete datasets were simulated containing five time points. Incomplete datasets were generated with 10, 25, and 50% missing data in follow-up costs and effects, assuming a Missing At Random (MAR) mechanism. Six different strategies were compared using empirical bias (EB), root-mean-squared error (RMSE), and coverage rate (CR). These strategies were: LLM alone (LLM) and MI with LLM (MI-LLM), and, as reference strategies, mean imputation with LLM (M-LLM), seemingly unrelated regression alone (SUR-CCA), MI with SUR (MI-SUR), and mean imputation with SUR (M-SUR). RESULTS: For costs and effects, LLM, MI-LLM, and MI-SUR performed better than M-LLM, SUR-CCA, and M-SUR, with smaller EBs and RMSEs as well as CRs closers to nominal levels. However, even though LLM, MI-LLM and MI-SUR performed equally well for effects, MI-LLM and MI-SUR were found to perform better than LLM for costs at 10 and 25% missing data. At 50% missing data, all strategies resulted in relatively high EBs and RMSEs for costs. CONCLUSION: LLM should be combined with MI when analyzing trial-based economic evaluation data. MI-SUR is more efficient and can also be used, but then an average intervention effect over time cannot be estimated.
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Análise Custo-Benefício , Humanos , Modelos Lineares , Simulação por ComputadorRESUMO
BACKGROUND: As resources for healthcare are scarce, decision-makers increasingly rely on economic evaluations when making reimbursement decisions about new health technologies, such as drugs, procedures, devices, and equipment. Economic evaluations compare the costs and effects of two or more interventions. Musculoskeletal disorders have a high prevalence and result in high levels of disability and high costs worldwide. Because physical therapy interventions are usually the first line of treatment for musculoskeletal disorders, economic evaluations of such interventions are becoming increasingly important for stakeholders in the field of physical therapy, including physical therapists, decision-makers, and reseachers. However, economic evaluations are relatively difficult to interpret for the majority of stakeholders. OBJECTIVE: To support physical therapists, decision-makers, and researchers in the field of physical therapy interpreting trial-based economic evaluations and translating the results of such studies to clinical practice. METHODS: The design, analysis, and interpretation of economic evaluations performed alongside randomized controlled trials are discussed. To further illustrate and explain these concepts, we use a case study assessing the cost-effectiveness of exercise therapy compared to standard advice in patients with musculoskeletal disorders. CONCLUSIONS: Economic evaluations are increasingly being used in healthcare decision-making. Therefore, it is of utmost importance that their design, conduct, and analysis are state-of-the-art and that their interpretation is adequate. This masterclass will help physical therapists, decision-makers, and researchers in the field of physical therapy to critically appraise the quality and results of trial-based economic evaluations and to apply the results of such studies to their own clinical practice and setting.
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Doenças Musculoesqueléticas , Modalidades de Fisioterapia , Análise Custo-Benefício , Tomada de Decisões , Atenção à Saúde , Humanos , Doenças Musculoesqueléticas/terapiaRESUMO
OBJECTIVE: This study aimed to establish the utility values of different health states associated with diabetic retinopathy in a Brazilian sample to provide input to model-based economic evaluations. METHODS: This cross-sectional study was performed in a sample of patients with type 2 diabetes mellitus (T2D) who underwent teleophthalmology screening at a primary care service from 2014 to 2016. Five diabetic retinopathy health states were defined: absent, non-sight-threatening, sight-threatening, and bilateral blindness. Utility values were estimated using the Brazilian EuroQol five dimensions (EQ-5D) tariffs. Descriptive statistics were calculated. Analysis of covariance was performed to adjust the utility values for potential confounders. RESULTS: The study included 206 patients. The mean (± standard deviation [SD]) utility value was 0.765 ± 0.19 (95% confidence interval [CI], 0.740-0.790). The adjusted mean utility value was 0.748 (95% CI, 0.698-0.798) in patients without diabetic retinopathy, 0.752 (95% CI, 0.679-0.825) in those with non-sight-threatening state, 0.628 (95% CI, 0.521-0.736) in those with sight-threatening state, and 0.355 (95% CI, 0.105-0.606) in those with bilateral blindness. A significant utility decrement was found between patients without diabetic retinopathy and those with a sight-threatening health state (0.748 vs. 0.628, respectively, p = 0.04). CONCLUSION: The findings suggest that a later diabetic retinopathy health state is associated with a decrement in utility value compared with the absence of retinopathy in patients with T2D. The results may be useful as preliminary input to model-based economic evaluations. Further research is needed to investigate the impact of diabetic retinopathy on health-related quality of life in a sample more representative of the Brazilian population.
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Diabetes Mellitus Tipo 2 , Retinopatia Diabética , Oftalmologia , Telemedicina , Brasil , Estudos Transversais , Diabetes Mellitus Tipo 2/complicações , Humanos , Atenção Primária à Saúde , Qualidade de VidaRESUMO
OBJECTIVE: To investigate the effectiveness of spinal manipulation combined with myofascial release compared with spinal manipulation alone, in individuals with chronic non-specific low back pain (CNLBP). DESIGN: Randomized controlled trial with three months follow-up. SETTING: Rehabilitation clinic. PARTICIPANTS: Seventy-two individuals (between 18 and 50 years of age; CNLBP ≥12 consecutive weeks) were enrolled and randomly allocated to one of two groups: (1) Spinal manipulation and myofascial release - SMMRG; n=36) or (2) Spinal manipulation alone (SMG; n=36). INTERVENTIONS: Combined spinal manipulation (characterized by high velocity/low amplitude thrusts) of the sacroiliac and lumbar spine and myofascial release of lumbar and sacroiliac muscles vs manipulation of the sacroiliac and lumbar spine alone, twice a week, for three weeks. MAIN OUTCOME MEASURES: Assessments were performed at baseline, three weeks post intervention and three months follow-up. Primary outcomes were pain intensity and disability. Secondary outcomes were quality of life, pressure pain-threshold and dynamic balance. RESULTS: No significant differences were found between SMMRG vs SMG in pain intensity and disability post intervention and at follow-up. We found an overall significant difference between-groups for CNLBP disability (SMG-SMMRG: mean difference of 5.0; 95% confidence interval of difference 9.9; -0.1), though this effect was not clinically important and was not sustained at follow-up. CONCLUSIONS: We demonstrated that spinal manipulation combined with myofascial release was not more effective compared to spinal manipulation alone for patients with CNLBP. CLINICAL TRIAL REGISTRATION NUMBER: NCT03113292.
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Dor Lombar/terapia , Manipulação da Coluna/métodos , Terapia de Tecidos Moles/métodos , Adolescente , Adulto , Avaliação da Deficiência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Equilíbrio Postural , Qualidade de Vida , Adulto JovemRESUMO
Patient no-show is a prevalent problem in health care services leading to inefficient resources allocation and limited access to care. This study aims to develop and validate a patient no-show predictive model based on empirical data. A retrospective study was performed using scheduled appointments between 2011 and 2014 from a Brazilian public primary care setting. Fifty percent of the dataset was randomly assigned to model development, and 50% was assigned to validation. Predictive models were developed using stepwise naïve and mixed-effect logistic regression along with the Akaike Information Criteria to select the best model. The area under the ROC curve (AUC) was used to assess the best model performance. Of the 57,586 scheduled appointments in the period, 70.7% (n = 40,740) were evaluated including 5,637 patients. The prevalence of no-show was 13.0% (n = 5,282). The best model presented an AUC of 80.9% (95% CI 80.1-81.7). The most important predictors were previous attendance and same-day appointments. The best model developed from data already available in the scheduling system, had a good performance to predict patient no-show. It is expected the model to be helpful to overbooking decision in the scheduling system. Further investigation is needed to explore the effectiveness of using this model in terms of improving service performance and its impact on quality of care compared to the usual practice.
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Pacientes não Comparecentes , Atenção Primária à Saúde , Adolescente , Adulto , Algoritmos , Agendamento de Consultas , Brasil , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Pacientes não Comparecentes/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Alocação de Recursos/estatística & dados numéricos , Estudos Retrospectivos , Adulto JovemRESUMO
ABSTRACT Objective This study aimed to establish the utility values of different health states associated with diabetic retinopathy in a Brazilian sample to provide input to model-based economic evaluations. Subjects and methods This cross-sectional study was performed in a sample of patients with type 2 diabetes mellitus (T2D) who underwent teleophthalmology screening at a primary care service from 2014 to 2016. Five diabetic retinopathy health states were defined: absent, non-sight-threatening, sight-threatening, and bilateral blindness. Utility values were estimated using the Brazilian EuroQol five dimensions (EQ-5D) tariffs. Descriptive statistics were calculated. Analysis of covariance was performed to adjust the utility values for potential confounders. Results The study included 206 patients. The mean (± standard deviation [SD]) utility value was 0.765 ± 0.19 (95% confidence interval [CI], 0.740-0.790). The adjusted mean utility value was 0.748 (95% CI, 0.698-0.798) in patients without diabetic retinopathy, 0.752 (95% CI, 0.679-0.825) in those with non-sight-threatening state, 0.628 (95% CI, 0.521-0.736) in those with sight-threatening state, and 0.355 (95% CI, 0.105-0.606) in those with bilateral blindness. A significant utility decrement was found between patients without diabetic retinopathy and those with a sight-threatening health state (0.748 vs. 0.628, respectively, p = 0.04). Conclusions The findings suggest that a later diabetic retinopathy health state is associated with a decrement in utility value compared with the absence of retinopathy in patients with T2D. The results may be useful as preliminary input to model-based economic evaluations. Further research is needed to investigate the impact of diabetic retinopathy on health-related quality of life in a sample more representative of the Brazilian population.
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Humanos , Oftalmologia , Telemedicina , Diabetes Mellitus Tipo 2/complicações , Retinopatia Diabética , Atenção Primária à Saúde , Qualidade de Vida , Brasil , Estudos TransversaisRESUMO
OBJECTIVE: To analyze the reliability and performance of the Portuguese version of questionnaires used to evaluate adherence to hypertensive treatment. METHODS: Hypertensive patients attending a primary healthcare unit in Porto Alegre, Southern Brazil, from January to September 2010, were randomly selected (n = 206). To evaluate adherence, Portuguese versions of the Morisky-Green test (MGT) and the Brief Medication Questionnaire (BMQ) were used. The analysis considered internal consistency, temporal stability and performance compared to three gold standards, which are: inadequate control of blood pressure (BP > 140/90 mmHg); insufficient rate of medication acquisition at the institution's pharmacy (<80%) and a combination of both factors. RESULTS: Of the patients studied, 97 only used medications dispensed by the Basic Health Unit. The tests showed good internal consistency by Cronbach's α: BMQ 0.66 (95%CI 0.60 to 0.73) and the MGT 0.73 (95%CI 0.67 to 0.79). The BMQ Regimen Screen had a sensitivity of 77%, specificity of 58%, and an area under the ROC curve of 0.70 (95%CI 0.55 to 0.86); for MGT sensitivity was 61%, specificity 36% and area under the ROC curve 0.46 (95%CI 0.30 to 0.62). The correlation between the BMQ and the MGT was r=0.28, p> 0.001. Low adherence per the BMQ is associated with higher blood pressure levels when compared to adherent patients (148.4 [SD 20.1] vs 128.8 [SD 17.8]; p <0.001), but not for the MGT. CONCLUSIONS: The BMQ showed better performance than the MGT, with greater sensitivity and specificity. Evaluation of adherence may help clinicians discriminate between inadequate use of medication and insufficient treatment regimen.
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Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Adesão à Medicação , Psicometria/métodos , Inquéritos e Questionários/normas , Idoso , Brasil , Estudos Transversais , Humanos , Masculino , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , TraduçãoRESUMO
Objective: To elaborate a blueprint of the competencies to be developed during three months of Family Medicine Clerkship at the Federal University of Health Sciences of Porto Alegre (UFCSPA). Methods: A literature review was carried out on competency-based education, medical schools using this approach and national and international guidelines on medical education. Therefore, the applicability of the recommendations in the context of UFCSPA Clerkship was discussed. Results: Eighteen competencies were established and divided into four axes: General, Individual Approach, Family Approach, and Community Approach. Each competency was depicted in one or more components. For each component, we have identified the teaching and students' assessment methods currently applied in Family Medicine Clerkship. Conclusions: Clerkship competencies, which were previously developed in an intuitive way, were organized in a blueprint that enables the review and adequacy of teaching methods and students' assessment.
Objetivo: Elaborar a matriz de competências a serem desenvolvidas pelos estudantes durante os três meses de estágio no internato em Medicina de Família e Comunidade na Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA). Métodos: Foi realizada revisão de literatura sobre o referencial teórico do ensino baseado em competências sobre escolas médicas que utilizassem o ensino baseado em competências na especialidade e sobre as principais diretrizes nacionais e internacionais sobre o tema. Diante da revisão de literatura, foi discutida a aplicabilidade das recomendações no contexto do internato da UFCSPA. Resultados: Dezoito competências foram elaboradas e divididas em quatro eixos: Geral; Abordagem Individual; Abordagem Familiar e Abordagem Comunitária. Cada competência foi detalhada em um ou mais componentes. Para cada componente, foram identificados os métodos de ensino e de avaliação atualmente utilizados no programa do internato. Conclusão: Com a definição da matriz, as competências, antes desenvolvidas de forma intuitiva, foram organizadas de modo a viabilizar a revisão e adequação dos processos de ensino e avaliação.
Objetivo: Elaborar una matriz de competencias, que debe ser desarrollada durante tres meses de Internado de Medicina Familiar y Comunitaria en la Universidad Federal de Ciencias de la Salud de Porto Alegre (UFCSPA). Métodos: Se realizó una revisión de la literatura sobre el marco teórico de la educación basada en competencias sobre las escuelas de medicina que utilizara la educación basada en competencias en la especialidad y sobre las principales directrices nacionales e internacionales sobre el tema. Por lo tanto, se discutió la aplicabilidad de las recomendaciones en el contexto del internado de UFCSPA. Resultados: Se elaboraron dieciocho competencias y se dividieron en cuatro ejes: General, Enfoque Individual, Enfoque Familiar y Enfoque Comunitario. Cada competencia se representó en uno o más componentes. Para cada componente se identificaron los métodos de enseñanza y de evaluación actualmente utilizados en el programa del internado. Conclusiones: Las competencias del Internado, antes desarrolladas de manera intuitiva, fueron organizadas en una matriz para hacer posible la revisión y adecuación de los métodos de enseñanza y la evaluación.
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Educação Baseada em Competências , Educação Médica , Medicina de Família e Comunidade , Internato e ResidênciaRESUMO
INTRODUÇÃO: A tuberculose merece especial atenção dos profissionais de saúde e da sociedade. Entretanto, os serviços de saúde não estão organizados para atender esses pacientes, e a prevalência da doença permanece alta no país. O objetivo deste estudo é demonstrar o papel da Atenção Primária na melhora dos indicadores da Tuberculose a partir de ações programáticas estruturadas. MÉTODOS: Dados de pacientes com diagnóstico de TB vinculados à Unidade Básica de Saúde do Hospital de Clínicas de Porto Alegre, atendidos nos serviços de saúde do município, foram analisados e comparados antes (2002 a 2008) e depois (2009 a 2012) da implantação de um Programa de Controle de Tuberculose. Os indicadores analisados têm base nas metas estabelecidas pela Organização Mundial da Saúde. RESULTADOS: Cento e quarenta pacientes tiveram Tuberculose entre 2002 e 2012: 94 no período pré-implantação do Programa e 46 após. Com o Programa, o número anual de sintomáticos respiratórios rastreados e de pacientes diagnosticados com Tuberculose cresceu. Aumentou o diagnóstico de Tuberculose nos serviços de atenção primária de 4,3% (n = 4) para 39,1% (n = 18), (p < 0,001); e houve melhora das taxas de cura (de 78,2% para 85,7%) e abandono (de 9,3% para 9,1%). CONCLUSÃO: Nosso estudo demonstrou que após a implantação do Programa de Controle de TB no Serviço de APS do HCPA houve melhora nos índices de diagnóstico da doença, nas taxas de cura e abandono, tendo sido atingida a meta de cura preconizada pelo Ministério da Saúde
INTRODUCTION: Tuberculosis deserves special attention from health professionals and society. However, health services are not organized to attend these patients, and the prevalence of the disease remains high in the country. The objective of this paper is to demonstrate the role of primary care in improving tuberculosis indicators with structured programmatic actions METHODS: Data from patients diagnosed with tuberculosis linked to the Primary Health Care Service of the Hospital de Clínicas de Porto Alegre, attended in the health care services of the city, were analyzed and compared before (2002-2008) and after (2009-2012) the implementation of a Tuberculosis Control Program. The indicators were analyzed based on the goals established by WHO. RESULTS: One hundred and forty patients had tuberculosis between 2002 and 2012, 94 before the implementation of the Program and 46 after. With the Program, the annual number of tracked respiratory symptomatic patients and patients diagnosed with tuberculosis increased. Also, the diagnosis of tuberculosis in primary care services increased from 4.3% (n = 4) to 39.1% (n = 18) (p < 0.001); and there was an improvement in cure (78.2% to 85.7%) and therapy dropout (9.3% to 9.1%) rates. CONCLUSION: Our study showed that, after implementation of the Tuberculosis Control Program in the Primary Health Care Service of the Hospital de Clínicas de Porto Alegre, there was improvement in diagnosis of the disease, cure and treatment dropout rates, which have reached the cure rate goal established by the Ministry of Health
Assuntos
Humanos , Tuberculose/diagnóstico , Tuberculose/terapia , Planos e Programas de Saúde , Atenção Primária à SaúdeRESUMO
OBJETIVO: Analisar a confiabilidade e o desempenho da versão em português de instrumentos de avaliação da adesão ao tratamento anti-hipertensivo. MÉTODOS: Pacientes hipertensos atendidos de janeiro a setembro de 2010 em uma unidade de atenção primária em Porto Alegre, RS, foram selecionados aleatoriamente (n = 206). Na avaliação da adesão foram utilizadas versões em português do Teste de Morisky-Green (TMG) e do Brief Medication Questionnaire (BMQ). Foram analisados consistência interna, estabilidade temporal e desempenho com relação a três padrões-ouro: controle inadequado da pressão arterial (> 140/90 mmHg); taxa insuficiente de retirada de medicação na farmácia da Unidade Básica de Saúde (< 80 por cento); e a combinação de ambos. RESULTADOS: Dos pacientes avaliados, 97 utilizavam medicamentos dispensados somente pela farmácia da Unidade Básica de Saúde. Os testes apresentaram boa consistência interna: BMQ α de Cronbach de 0,66 (IC95 por cento 0,60;0,73) e o TMG 0,73 (IC95 por cento 0,67;0,79). O desempenho do BMQ no domínio regime apresentou sensibilidade de 77 por cento, especificidade de 58 por cento e área sob a curva ROC de 0,70 (IC95 por cento 0,55;0,86), e o TMG sensibilidade de 61 por cento, especificidade de 36 por cento e área sob a curva ROC de 0,46 (IC95 por cento 0,30;0,62). A correlação entre o BMQ e o TMG foi de r = 0,28, p > 0,001. A baixa adesão ao BMQ está associada a maiores níveis tensionais quando comparada com pacientes aderentes (148,4 [dp 20,1] vs 128,8 [dp 17,8], p < 0,001), mas não para o TMG. CONCLUSÕES: O BMQ apresentou melhor desempenho que o TMG, com maiores sensibilidade e especificidade. A avaliação da adesão pode auxiliar o clinico na discriminação entre uso inadequado da medicação e esquema terapêutico insuficiente.
OBJECTIVE: To analyze the reliability and performance of the Portuguese version of questionnaires used to evaluate adherence to hypertensive treatment. METHODS: Hypertensive patients attending a primary healthcare unit in Porto Alegre, Southern Brazil, from January to September 2010, were randomly selected (n = 206). To evaluate adherence, Portuguese versions of the Morisky-Green test (MGT) and the Brief Medication Questionnaire (BMQ) were used. The analysis considered internal consistency, temporal stability and performance compared to three gold standards, which are: inadequate control of blood pressure (BP > 140/90 mmHg); insufficient rate of medication acquisition at the institution's pharmacy (<80 percent) and a combination of both factors. RESULTS: Of the patients studied, 97 only used medications dispensed by the Basic Health Unit. The tests showed good internal consistency by Cronbach's α: BMQ 0.66 (95 percentCI 0.60 to 0.73) and the MGT 0.73 (95 percentCI 0.67 to 0.79). The BMQ Regimen Screen had a sensitivity of 77 percent, specificity of 58 percent, and an area under the ROC curve of 0.70 (95 percentCI 0.55 to 0.86); for MGT sensitivity was 61 percent, specificity 36 percent and area under the ROC curve 0.46 (95 percentCI 0.30 to 0.62). The correlation between the BMQ and the MGT was r=0.28, p> 0.001. Low adherence per the BMQ is associated with higher blood pressure levels when compared to adherent patients (148.4 [SD 20.1] vs 128.8 [SD 17.8]; p <0.001), but not for the MGT. CONCLUSIONS: The BMQ showed better performance than the MGT, with greater sensitivity and specificity. Evaluation of adherence may help clinicians discriminate between inadequate use of medication and insufficient treatment regimen.
OBJETIVO: Analizar la confiabilidad y el desempeño de la versión en portugués de instrumentos de evaluación de la adherencia al tratamiento antihipertensivo. MÉTODOS: Pacientes hipertensos atendidos de enero a septiembre de 2010 en una unidad de atención primaria en Porto Alegre, Sur de Brasil, fueron seleccionados aleatoriamente (n=206). En la evaluación de la adherencia fueron utilizadas versiones en portugués de la Prueba de Morisky-Green (TMG) y del Brief Medication Questionnarie (BMQ). Se analizaron consistencia interna, estabilidad temporal y desempeño con relación a tres patrones-oro: control inadecuado de la presión arterial (> 140/90 mmHg); tasa insuficiente de retirada de medicación en la farmacia de la Unidad Básica de Salud (< 80 por ciento) y la combinación de ambos. RESULTADOS: De los pacientes evaluados, 97 utilizaban medicamentos dispensados solamente por la farmacia de la Unidad Básica de Salud. Las pruebas presentaron buena consistencia interna: BMQ α de Cronbach de 0,66 (IC95 por ciento 0,60;0,73) y el TMG 0,73 (IC95 por ciento 0,67;0,79). El desempeño del BMQ en el dominio régimen presentó sensibilidad de 77 por ciento, especificidad de 58 por ciento, y área bajo la curva ROC de 0,70 (IC95 por ciento 0,55;0,86) y el TMG sensibilidad de 61 por ciento, especificidad de 36 por ciento y área bajo la curva ROC de 0,46 (IC95 por ciento 0,30;0,62). La correlación entre el BMQ y el TMG fue de r=0,28, p>0,001. La baja adherencia al BMQ está asociada a mayores niveles tensionales al compararlo con pacientes adherentes 148,4 [de 0,1] vs 128,8 [de 17,8], p<0,001), pero no para el TMG. CONCLUSIONES: El BMQ presentó mejor desempeño que el TMG, con mayor sensibilidad y especificidad. La evaluación de la adherencia puede auxiliar al clínico en la discriminación entre el uso inadecuado de la medicación y esquema terapéutico insuficiente.
Assuntos
Idoso , Humanos , Masculino , Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Adesão à Medicação , Psicometria/métodos , Inquéritos e Questionários/normas , Brasil , Estudos Transversais , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , TraduçãoRESUMO
Introdução: a regionalização do controle da tuberculose (TB) é uma das metas da Vigilância (CGVS) buscando reduzir os casos de abandono do tratamento e aumentar a taxa de diagnóstico. A análise dos resultados prévios das áreas a serem regionalizadas é importante para manter e ampliar a qualidade do controle da tuberculose, além de ser uma das etapas iniciais do planejamento da atenção à saúde. Objetivo: a regionalização do atendimento à TB na área da UBS HCPA visa: (1) descentralizar a estratégia de diagnóstico e tratamento da TB; (2) implantar um sistema coordenado de atenção com foco na atenção primária; (3) georreferenciar os pacientes para otimizar a vigilância local; (4) contribuir para o treinamento dos médicos residentes em medicina de família HCPA na área de gestão dos programas da atenção primária; e (5) contribuir na redução das taxas de abandono ao tratamento. Materiais e Métodos: Fase 1 - realizou-se a estimativa do número de casos, georreferenciamento dos casos notificados e a análise da coorte utilizando os dados históricos da região de abrangência da UBS HCPA no período de janeiro de 2004 até julho de 2008, data da implantação do serviço regionalizado buscando os indicadores de atenção deste período. Fase 2 Foram criados fluxogramas de rastreamento, diagnóstico e tratamento e foi iniciado o atendimento sob supervisão. Resultados: a incidência média de TB nessa região é de aproximadamente 0,5/100.000hab/ano. Foram realizados mapas georeferenciados dos casos. Foram notificados 88 pacientes entre 1/2004 a 7/2008, sendo 55,7% da forma pulmonar (idade 39,6 ±16,8 anos), 37,5% extra-pulmonar (idade 48,2 ±17,5 anos) e o restante, formas mistas. Quanto ao local de diagnóstico: 1% na atenção primária, 89% na atenção secundária e os demais na atenção terciária. Nos casos de TB pulmonar, a baciloscopia foi positiva em 57,1% e não realizada em 18% dos casos. Com relação ao tratamento as taxas foram 75,1%, para cura e 8,5% de abandono. Os dados do início da implantação (3 meses) mostram a pesquisa de 25 sintomáticos respiratórios por mês, o diagnóstico de um caso novo e a busca ativa de 100% dos faltosos. Conclusões: os resultados prévios da área mostram taxas de sucesso e de abandono abaixo das metas estabelecidas. A taxa de diagnóstico na atenção primária é baixa. Em função disso a descentralização deve ser acompanhada por um aumento do rastreamento dos sintomáticos respiratórios e busca ativa dos contatos, visando aumentar o diagnóstico e o desenvolvimento de tratamento supervisionado (ADOT) buscando reduzir o abandono.
Introduction: The regionalization of control of tuberculosis (TB) is one of the aims of the vigilance (CGVS) seeking to reduce the cases of treatment abandonment and to raise the diagnostic rate. The analysis of previous results of the areas yet to be regionalized is important to maintain and amplify the quality of TB control, besides being one of the first steps of the attention to health plan. Objective: the regionalization of TB treatment in the USB HCPA area aims to: decentralize the diagnostic strategy and TB treatment; implant a system attention coordinated with focus on the primary attention; georeference the patients in order to optimize the local vigilance; contribute to the training of the resident doctors in HCPA family medicine in the management area of the primary attention programs; and contribute in the reduction of the treatment abandonment rate. Materials and Methods: Phase 1 an estimate of the number of cases was done, notified cases were georeferenced and an analysis of the cohort was carried out, using the regional historic data on the UBS HCPA reach in the period from January 2004 to July 2008, implantation date of the regionalization service searching for the attention indicators of this period. Phase 2 tracking, diagnosis and treatment fluxograms were created, and attendance under supervision was initialized. Results: The average incidence of TB in this region is of approximately 0.5/100,000 inhabitants/year. Georeferenced maps of the cases were made. Eightyeight patients were notified between 1/2004 to 7/2008, being 55.7% pulmonary (age 39.6 ±16.8 years), 37.5% extra pulmonary (age 48.2 ±17.5 years) and the rest, mixed forms. As for the location of diagnostic: 1% in primary attention, 89% in secondary attention and the remainder in the tertiary attention. In the cases of pulmonary TB, the smear was positive in 57.1% and not done in 18% of the cases. Regarding the treatment, the rates were 75.1% of cure and 8.5% of abandonment. The data from the start of implantation (3 months) show the research of 25 respiratory symptomatic per month, the diagnosis of one new case and the active search by 100% of the absent subjects. Conclusions: The previous results of the area show rates of success and of abandonment below the established goals. The ratio of diagnosis in primary attention is low. Because of that, the decentralization should be accompanied with a raise on tracking of respiratory symptomatic patients and active search of contacts, aimimg to raise the diagnosis and development of supervised treatment (ADOT), seeking to reduce abandonment.
Introducción: La regionalización del control de la tuberculosis (TB) es una de las metas de la vigilancia (CGVS), buscando reducir los casos de abandono del tratamiento y aumentar la tasa de diagnóstico. El análisis de los resultados previos de las áreas regionales es importante para mantener y ampliar la cantidad del control de la tuberculosis, además de ser una de las etapas iníciales del planeamiento de la atención a la salud. Objetivo: La regionalización del atendimiento a la TB en área da UBS HCPA visa: (1) descentralizar la estrategia del diagnóstico y tratamiento de la TB; (2) implantar un sistema coordinado de atención focalizado en atención primaria, (3) analizar los pacientes para optimizar la vigilancia local; (4) contribuir para o entrenamiento de los médicos residentes en medicina familiar HCPA en área de gestión de los programas de atención primaria; (5) contribuir en la reducción de las tasas de abandono al tratamiento. Materiales y Métodos: Fase 1- se realizó la estimativa del número de los casos, localización de los casos notificados y el análisis da coorte utilizando los datos históricos de la región de cobertura de la UBS HCPA en período de enero de 2004 hasta Julio de 2008, dada la implantación del servicio regionalizado buscando los indicadores de atención de este período.Fase2- Han sido creados fluxogramas de rastreamento, diagnósticos y tratamiento, y ha sido indicado en atendimiento bajo supervisión. Resultados: La incidencia media de TB en esta región es próximamente 0,5/100.000 hab/año. Han sido realizados mapas pesquisa de los casos. Se notificaron 88 pacientes entre 1/2004 a 7/2008, siendo 55,7% de la forma pulmonar (edad 39,6 a 16,8 años), 37,5% extra pulmonar (edad 48,2 a 17,5 años) y el restante, formas mistas. En cuanto al local de diagnóstico: 1% en la atención primaria, 89% en la atención secundaria y los además en la atención terciaria. En los casos de TB pulmonar, la baciloscopia ha sido positiva en 57,1% y no realizadas en 18% de los casos. En relación al tratamiento las tasas son de 75,1% para cura y 8,5% de abandono. Los datos del inicio de la implantación (3meses) indican la pesquisa de 25 sintomáticos respiratorios al mes, el diagnostico de un caso nuevo y la búsqueda activa de 100% de los faltosos. Conclusiones: Los resultados previos del área indican tasas de suceso y de abandono abajo de las metas establecidas. La tasa de diagnósticos en la atención primaria es baja. Así, la descentralización debe ser acompañada por un aumento del rastreamento de los sintomáticos respiratorios y la búsqueda activa de los contactos, visando aumentar el diagnóstico y el desarrollo del tratamiento supervisionado (ADOT) buscando reducir el abandono