Clinical characteristics and outcomes of COVID-19 patients with preexisting dementia: a large multicenter propensity-matched Brazilian cohort study.

BACKGROUND: Although dementia has emerged as an important risk factor for severe SARS-CoV-2 infection, results on COVID-19-related complications and mortality are not consistent. We examined the clinical presentations and outcomes of COVID-19 in a multicentre cohort of in-hospital patients, comparing those with and without dementia. METHODS: This retrospective observational study comprises COVID-19 laboratory-confirmed patients aged ≥ 60 years admitted to 38 hospitals from 19 cities in Brazil. Data were obtained from electronic hospital records. A propensity score analysis was used to match patients with and without dementia (up to 3:1) according to age, sex, comorbidities, year, and hospital of admission. Our primary outcome was in-hospital mortality. We also assessed admission to the intensive care unit (ICU), invasive mechanical ventilation (IMV), kidney replacement therapy (KRT), sepsis, nosocomial infection, and thromboembolic events. RESULTS: Among 1,556 patients included in the study, 405 (4.5%) had a diagnosis of dementia and 1,151 were matched controls. When compared to matched controls, patients with dementia had a lower frequency of dyspnoea, cough, myalgia, headache, ageusia, and anosmia; and higher frequency of fever and delirium. They also had a lower frequency of ICU admission (32.7% vs. 47.1%, p < 0.001) and shorter ICU length of stay (7 vs. 9 days, p < 0.026), and a lower frequency of sepsis (17% vs. 24%, p = 0.005), KRT (6.4% vs. 13%, p < 0.001), and IVM (4.6% vs. 9.8%, p = 0.002). There were no differences in hospital mortality between groups. CONCLUSION: Clinical manifestations of COVID-19 differ between older inpatients with and without dementia. We observed that dementia alone could not explain the higher short-term mortality following severe COVID-19. Therefore, clinicians should consider other risk factors such as acute morbidity severity and baseline frailty when evaluating the prognosis of older adults with dementia hospitalised with COVID-19.

Understanding the municipal-level design and adaptation of pay-for-performance schemes across two states of Brazil.

The design of complex health systems interventions, such as pay for performance (P4P), can be critical to determining such programmes' success. In P4P programmes, the design of financial incentives is crucial in shaping how these programmes work. However, the design of such schemes is usually homogenous across providers within a given scheme. Consequently, there is a limited understanding of the strengths and weaknesses of P4P design elements from the implementers' perspective. This study takes advantage of the unique context of Brazil, where municipalities adapted the federal incentive design, resulting in variations in incentive design across municipalities. The study aims to understand why municipalities in Brazil chose certain P4P design features, the associated challenges, and the local adaptations made to address problems in scheme design. This study was a multiple-case study design relying on qualitative data from twenty municipalities from two states in northeastern Brazil. We conducted two key informant interviews with municipal-level stakeholders and focus group discussions with primary care providers. We also reviewed municipal PMAQ laws in each municipality. We found substantial variation in the design choices made by municipalities regarding 'who was incentivised', the 'payment size' and 'frequency'. Design choices affected relationships within municipalities and within teams. Challenges were chiefly associated with fairness relating to 'who received the incentive', 'what is incentivised', and the 'incentive size'. Adaptations were made to improve fairness, mostly in response to pressure from the healthcare workers. The significant variation in design choices across municipalities and providers' response to them highlights the importance of considering local context in the design and implementation of P4P schemes and ensuring flexibility to accommodate local preferences and emerging needs. Attention is needed to ensure the choice of 'who is incentivised' and the 'size of incentives' are inclusive and fair, and the allocation and 'use of funds' are transparent.

Does pay-for-performance design matter? Evidence from Brazil.

Pay-for-performance (P4P) schemes have been shown to have mixed effects on health care outcomes. A challenge in interpreting this evidence is that P4P is often considered a homogenous intervention, when in practice schemes vary widely in their design. Our study contributes to this literature by providing a detailed depiction of incentive design across municipalities within a national P4P scheme in Brazil [Primary Care Access and Quality (PMAQ)] and exploring the association of alternative design typologies with the performance of primary health care providers. We carried out a nation-wide survey of municipal health managers to characterize the scheme design, based on the size of the bonus, the providers incentivized and the frequency of payment. Using OLS regressions and controlling for municipality characteristics, we examined whether each design feature was associated with better family health team (FHT) performance. To capture potential interactions between design features, we used cluster analysis to group municipalities into five design typologies and then examined associations with quality of care. A majority of the municipalities included in our study used some of the PMAQ funds to provide bonuses to FHT workers, while the remaining municipalities spent the funds in the traditional way using input-based budgets. Frequent bonus payments (monthly) and higher size bonus allocations (share of 20-80%) were strongly associated with better team performance, while who within a team was eligible to receive bonuses did not in isolation appear to influence performance. The cluster analysis showed what combinations of design features were associated with better performance. The PMAQ score in the 'large bonus/many workers/high-frequency' cluster was 8.44 points higher than the 'no bonus' cluster, equivalent to a difference of 21.7% in the mean PMAQ score. Evidence from our study shows how design features can potentially influence health provider performance, informing the design of more effective P4P schemes.

Pay-for-performance for primary health care in Brazil: A comparison with England's Quality Outcomes Framework and lessons for the future.

Pay-for-performance (P4P) has been widely applied in OECD countries to improve the quality of both primary and secondary care, and is increasingly being implemented in low- and middle-income countries. In 2011, Brazil introduced one of the largest P4P schemes in the world, the National Programme for Improving Primary Care Access and Quality (PMAQ). We critically assess the design of PMAQ, drawing on a comparison with England's quality and outcome framework which, like PMAQ, was implemented at scale relatively rapidly within a nationalised health system. A key feature of PMAQ was that payment was based on the performance of primary care teams but rewards were given to municipalities, who had autonomy in how the funds could be used. This meant the incentives felt by family health teams were contingent on municipality decisions on whether to pass the funds on as bonuses and the basis upon which they allocated the funds between and within teams. Compared with England's P4P scheme, performance measurement under PMAQ focused more on structural rather than process quality of care, relied on many more indicators, and was less regular. While PMAQ represented an important new funding stream for primary health care, our review suggests that theoretical incentives generated were unclear and could have been better structured to direct health providers towards improvements in quality of care.

Myocardial Injury and Prognosis in Hospitalized COVID-19 Patients in Brazil: Results From The Brazilian COVID-19 Registry. / Lesão Miocárdica e Prognóstico em Pacientes Hospitalizados com COVID-19 no Brasil: Resultados do Registro Nacional de COVID-19.

BACKGROUND: Cardiovascular complications of COVID-19 are important aspects of the disease's pathogenesis and prognosis. Evidence on the prognostic role of troponin and myocardial injury in Latin American hospitalized COVID-19 patients is still scarce. OBJECTIVES: To evaluate myocardial injury as independent predictor of in-hospital mortality and invasive mechanical ventilation support in hospitalized patients, from the Brazilian COVID-19 Registry. METHODS: This cohort study is a substudy of the Brazilian COVID-19 Registry, conducted in 31 Brazilian hospitals of 17 cities, March-September 2020. Primary outcomes included in-hospital mortality and invasive mechanical ventilation support. Models for the primary outcomes were estimated by Poisson regression with robust variance, with statistical significance of p<0.05. RESULTS: Of 2,925 patients (median age of 60 years [48-71], 57.1% men), 27.3% presented myocardial injury. The proportion of patients with comorbidities was higher among patients with cardiac injury (median 2 [1-2] vs. 1 [0-2]). Patients with myocardial injury had higher median levels of brain natriuretic peptide, lactate dehydrogenase, creatine phosphokinase, N-terminal pro-brain natriuretic peptide, and C-reactive protein than patients without myocardial injury. As independent predictors, C-reactive protein and platelet counts were related to the risk of death, and neutrophils and platelet counts were related to the risk of invasive mechanical ventilation support. Patients with high troponin levels presented a higher risk of death (RR 2.03, 95% CI 1.60-2.58) and invasive mechanical ventilation support (RR 1.87, 95% CI 1.57-2.23), when compared to those with normal troponin levels. CONCLUSION: Cardiac injury was an independent predictor of in-hospital mortality and the need for invasive mechanical ventilation support in hospitalized COVID-19 patients.

FUNDAMENTO: As complicações cardiovasculares da COVID-19 são aspectos importantes da patogênese e do prognóstico da doença. Evidências do papel prognóstico da troponina e da lesão miocárdica em pacientes hospitalizados com COVID-19 na América Latina são ainda escassos. OBJETIVOS: Avaliar a lesão miocárdica como preditor independente de mortalidade hospitalar e suporte ventilatório mecânico em pacientes hospitalizados, do registro brasileiro de COVID-19. MÉTODOS: Este estudo coorte é um subestudo do registro brasileiro de COVID-19, conduzido em 31 hospitais brasileiros de 17 cidades, de março a setembro de 2020. Os desfechos primários incluíram mortalidade hospitalar e suporte ventilatório mecânico invasivo. Os modelos para os desfechos primários foram estimados por regressão de Poisson com variância robusta, com significância estatística de p<0,05. RESULTADOS: Dos 2925 pacientes [idade mediana de 60 anos (48-71), 57,1%], 27,3% apresentaram lesão miocárdica. A proporção de pacientes com comorbidades foi maior nos pacientes com lesão miocárdica [mediana 2 (1-2) vs. 1 (0-20)]. Os pacientes com lesão miocárdica apresentaram maiores valores medianos de peptídeo natriurético cerebral, lactato desidrogenase, creatina fosfoquinase, N-terminal do pró-peptídeo natriurético tipo B e proteína C reativa em comparação a pacientes sem lesão miocárdica. Como fatores independentes, proteína C reativa e contagem de plaquetas foram relacionados com o risco de morte, e neutrófilos e contagem de plaquetas foram relacionados ao risco de suporte ventilatório mecânico invasivo. Os pacientes com níveis elevados de troponina apresentaram um maior risco de morte (RR 2,03, IC95% 1,60-2,58) e suporte ventilatório mecânico (RR 1,87;IC95% 1,57-2,23), em comparação àqueles com níveis de troponina normais. CONCLUSÃO: Lesão cardíaca foi um preditor independente de mortalidade hospitalar e necessidade de suporte ventilatório mecânico em pacientes hospitalizados com COVID-19.

Frequency and burden of neurological manifestations upon hospital presentation in COVID-19 patients: Findings from a large Brazilian cohort.

BACKGROUND: Scientific data regarding the prevalence of COVID-19 neurological manifestations and prognosis in Latin America countries is still lacking. Therefore, the study aims to understand neurological manifestations of SARS-CoV 2 infection and outcomes in the Brazilian population. METHODS: This study is part of the Brazilian COVID-19 Registry, a multicentric cohort, including data from 37 hospitals. For the present analysis, patients were grouped according to the presence of reported symptoms (i.e., headache; anosmia and ageusia; syncope and dizziness) vs. clinically-diagnosed neurological manifestations (clinically-defined neurological syndrome: neurological signs or diagnoses captured by clinical evaluation) and matched with patients without neurological manifestations by age, sex, number of comorbidities, hospital of admission, and whether or not patients had underlying neurological disease. RESULTS: From 6,635 hospitalized patients with COVID-19, 30.8% presented reported neurological manifestations, 10.3% were diagnosed with a neurological syndrome and 60.1% did not show any neurological manifestations. In patients with reported symptoms, the most common ones were headache (20.7%), ageusia (11.1%) and anosmia (8.0%). In patients with neurological syndromes, acute encephalopathy was the most common diagnosis (9.7%). In the matched analysis, patients with neurological syndromes presented more cases of septic shock (17.0 vs. 13.0%, p = 0.045), intensive care unit admission (45.3 vs. 38.9%, p = 0.023), and mortality (38.7 vs. 32.6%, p = 0.026; and 39.2 vs. 30.3%, p < 0.001) when compared to controls. CONCLUSION: COVID-19 in-hospital patients with clinically defined neurological syndromes presented a higher incidence of septic shock, ICU admission and death when compared to controls.

Pay for performance in primary care: the contribution of the Programme for Improving Access and Quality of Primary Care (PMAQ) on avoidable hospitalisations in Brazil, 2009-2018.

BACKGROUND: Evidence on the effect of pay-for-performance (P4P) schemes on provider performance is mixed in low-income and middle-income countries. Brazil introduced its first national-level P4P scheme in 2011 (PMAQ-Brazilian National Programme for Improving Primary Care Access and Quality). PMAQ is likely one of the largest P4P schemes in the world. We estimate the association between PMAQ and hospitalisations for ambulatory care sensitive conditions (ACSCs) based on a panel of 5564 municipalities. METHODS: We conducted a fixed effect panel data analysis over the period of 2009-2018, controlling for coverage of primary healthcare, hospital beds per 10 000 population, education, real gross domestic product per capita and population density. The outcome is the hospitalisation rate for ACSCs among people aged 64 years and under per 10 000 population. Our exposure variable is defined as the percentage of family health teams participating in PMAQ, which captures the roll-out of PMAQ over time. We also provided several sensitivity analyses, by using alternative measures of the exposure and outcome variables, and a placebo test using transport accident hospitalisations instead of ACSCs. RESULTS: The results show a negative and statistically significant association between the rollout of PMAQ and ACSC rates for all age groups. An increase in PMAQ participating of one percentage point decreased the hospitalisation rate for ACSC by 0.0356 (SE 0.0123, p=0.004) per 10 000 population (aged 0-64 years). This corresponds to a reduction of approximately 60 829 hospitalisations in 2018. The impact is stronger for children under 5 years (-0.0940, SE 0.0375, p=0.012), representing a reduction of around 11 936 hospitalisations. Our placebo test shows that the association of PMAQ on the hospitalisation rate for transport accidents is not statistically significant, as expected. CONCLUSION: We find that PMAQ was associated with a modest reduction in hospitalisation for ACSCs.

Cost analysis in a Traditional, Complementary and Integrative Medicine unit in Brazil.

OBJECTIVE: To analyze the costs of a specialized service in Traditional Complementary and Integrative Medicines (TCIM) in Northeast Brazil to provide data on the cost linked to the implementation and maintenance of services of this nature and to identify the average cost per user for the Unified Health System. METHODS: This is a partial, descriptive, quantitative economic assessment, which used secondary data, later grouped in Microsoft Excel spreadsheets. The method used to analyze such costs was absorption costing, from which the service was divided into three costing centers: productive, administrative and auxiliary. RESULTS: After analyzing the data, the total cost of the service in 2014 was estimated at R$ 1,270,015.70, with a proportion of 79.69% of direct costs. The average cost per user in this period was R$ 36.79, considering the total of 34,521 users in individual and collective practices. CONCLUSIONS: The service has a cost per user compatible with a specialized service; however, TCIM offers a comprehensive and holistic approach, which can have a positive impact on quality of life.

Elderly retirement postponement factors: an integrative literature review. / Fatores de postergação da aposentadoria de idosos: revisão integrativa da literatura.

This study aimed to search for scientific evidence published in analytical studies which address elderly workers' retirement postponement factors. An integrative literature review was performed searching for papers in Virtual Health Library (BVS) and SciELO databases from January 2009 to March 2018. Twelve papers were selected following consensus by independent reviewers, generating two categories: National Literature and International Literature. We chose this subject because the phenomenon of population aging entails different social and economic impacts between developed and developing nations, such as Brazil. In the analysis of the results, we found that elderly retirement decision involves a variety of personal, organizational and other factors (legislative, cultural, socio-political, technological). In conclusion, we note scarcity of studies on the subject, with exclusive samples of older adults in both categories, as well as that the greater or lesser relevance of a given factor will depend on the life context of each worker. Moreover, since retirement decision is a dynamic process, there is a shortage of longitudinal studies that need to be met with more robust national surveys of the elderly population.

O presente estudo objetivou a busca de evidências científicas publicadas em estudos analíticos que versam sobre fatores de postergação da aposentadoria de trabalhadores idosos. Foi realizada uma revisão integrativa da literatura com busca de artigos originais nas bases da Biblioteca Virtual de Saúde e SciELO no período de janeiro/2009 a março/2018. Foram selecionados 12 artigos após consenso de revisores independentes gerando duas categorias: Literatura Nacional e Literatura Internacional. Tal escolha foi porque o fenômeno do envelhecimento populacional acarreta impactos sociais e econômicos diferentes entre as nações desenvolvidas e naquelas em desenvolvimento, como o Brasil. Na análise dos resultados encontramos que a decisão de aposentadoria dos idosos envolve uma variedade de fatores pessoais, organizacionais e outros (legislativos, culturais, sociopolíticos e tecnológicos). Em conclusão constatamos a escassez de estudos na temática com amostras exclusivasde idosos em ambas as categorias, assim como a maior ou menor relevância de determinado fator dependerá do contexto de vida de cada trabalhador. Além do mais, como a decisão de aposentadoria é um processo dinâmico, existe carência de estudos longitudinais que necessitam ser supridos com pesquisas mais robustas nacionais da população idosa.

Caminhos possíveis da avaliação econômica para práticas integrativas e complementares nas condições crônicas / Possible paths of economic assessment for integrative and complementary practices in chronic conditions

Resumo Objetivos Analisar desenhos de avaliação econômica em Práticas Integrativas e Complementares em Saúde (PICS). Métodos O estudo é uma revisão integrativa de estudos disponíveis na Biblioteca Virtual em Saúde, de 2009 a 2021. Resultados Vinte e um estudos foram selecionados para análise final, apresentando importante conformidade com as recomendações dos especialistas. Em geral, a população foi composta por mulheres adultas com distúrbios osteomusculares, que receberam terapias manipulativas, acupuntura/acupressão e homeopatia. Para avaliar essas intervenções, foram utilizadas as perspectivas da sociedade ou do provedor, a partir de análises de custo-efetividade e de custo-consequência, concentrando-se em estimar os custos diretos de saúde, e por vezes, os custos indiretos. Quanto aos desfechos, a maioria dos estudos coletou mais de uma medida, principalmente relacionadas a manifestações sintomáticas, bem-estar global e/ou fatores psicossociais. Conclusões A avaliação econômica está evoluindo para considerar perspectivas mais amplas, com maior variedade de custos e resultados, adaptando-se a diversos cenários de intervenção, atendendo às especificidades das PICS. Conciliar o desenho metodológico ao contexto de inserção das PICS no Brasil é possível e necessário, dada a carência de avaliações nacionais, aos vieses gerados por comparações internacionais e às disputas pela sustentabilidade desse conjunto de práticas no Sistema Único de Saúde.

Abstract Objectives To analyze economic evaluation designs in Integrative and Complementary Health Practices (PICS). Methods This study is an integrative review of available studies in the Virtual Health Library, from 2009 to 2021. Results Twenty-one studies were selected for final analysis, showing significant compliance with the experts' recommendations. In general, the population consisted of adult women with musculoskeletal disorders, who received manipulative therapies, acupuncture/acupressure and homeopathy. To evaluate these interventions, society's or provider's perspectives were used, based on cost-effectiveness and cost-consequence analyses, focusing on estimating direct health costs, and sometimes indirect costs. As for outcomes, most studies collected more than one measure, mainly related to symptomatic manifestations, overall well-being and/or psychosocial factors. Conclusions The economic evaluation is evolving to consider broader perspectives, with a greater variety of costs and results, adapting to different intervention scenarios, meeting the specificities of PICS. Reconciling methodological design and PICS' context of insertion in Brazil is possible and necessary, given the lack of national assessments, the biases generated by international comparisons, and the disputes over the sustainability of this set of practices in the Brazilian Unified Healht System.

Influence of the Mais Médicos (More Doctors) Program on health services access and use in Northeast Brazil.

OBJECTIVE: To evaluate the influence of the Mais Médicos (More Doctors) Program on the performance of primary health care by quantifying health services access and use in Northeast Brazil, based on the population size of the municipalities, on the financial investment in health, and on the number of physicians in the family health teams. METHOD: Evaluative research of quantitative nature. Access was evaluated by the population coverage ratio of the Family Health Strategy and use of health services, which were measured by medical appointments conducted between April 2013 and September 2015. We defined processes for database selection, adjustment, and validation, including explanatory variables for a sample of 896 municipalities. The analysis was based on the time periods before and after the implementation of the program. The Wilcoxon signed-rank test and non-parametric alternatives constituted statistical tests in the comparative analysis of the data. RESULTS: A 19.2% increase was observed in the number of medical appointments between the first six months and the final six months of the data series. In this period, the median appointments in municipalities with up to 5,000 inhabitants increased from 701.0 to 768.0; while in those with more than 100,000 inhabitants it decreased from 285.5 to 280.0 (p < 0.05). Between April 2013 and September 2015, the median coverage ratio of the family health teams increased from 89.2% to 95.3%, approaching 100% in the municipalities with up to 20,000 inhabitants. CONCLUSIONS: The study highlights the expansion of access and use of primary health care services in the northeast region after the implementation of the Mais Médicos (More Doctors) Program. Between April 2013 and September 2015, the coverage of family health teams and the production of medical appointments increased, constituting important achievements for SUS.

[Supply of Integrative and Complementary Health Practices in the Family Health Strategy in Brazil]. / Oferta de Práticas Integrativas e Complementares em Saúde na Estratégia Saúde da Família no Brasil.

The article analyzes the supply of Integrative and Complementary Health Practices in the Family Health Strategy (FHS), based on the agreement between answers by administrators and health professionals. This was a quantitative descriptive-exploratory study using two databases, the National Survey on Integrative and Complementary Practices in Health in the Unified National Health System (SUS) and the National Program for Improvement of Access and Quality of Basic Care (PMAQ). According to the administrators, the supply of Integrative and Complementary Health Practices was present in the FHS in 26.7% of the municipalities participating in the National Survey, compared to 25.5% of the municipalities according to the health professionals in the PMAQ. Of the 1,478 municipalities that participated in both surveys, in 8.6% there was an agreement of answers on the supply of Integrative and Complementary Health Practices in the FHS. The municipalities with the greatest agreement in the supply were those with small populations and greater coverage of basic care. The small proportion of municipalities with this supply according to both administrators and health professionals supports the hypothesis that the health professionals are the main force responsible for the expansion of Integrative and Complementary Health Practices in the SUS, as compared to initiatives by administrators. This scenario reflects the need for administrators to take greater stock of what is developed in the FHS to strengthen Integrative and Complementary Health Practices and to mobilize the institutional resources for their maintenance and expansion.

O artigo apresenta análise da oferta das Práticas Integrativas e Complementares em Saúde (PICS) na Estratégia Saúde da Família (ESF), a partir da convergência da resposta de gestores e profissionais. Trata-se de uma pesquisa quantitativa descritivo-exploratória, utilizando dois bancos de dados: o Inquérito Nacional de Práticas Integrativas e Complementares em Saúde no SUS e o Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ). De acordo com os gestores, a oferta de PICS esteve presente na ESF de 26,7% dos municípios participantes do Inquérito e em 25,5% dos municípios do PMAQ, segundo os profissionais. Dos 1.478 municípios que participaram das duas pesquisas, em 8,6% deles houve convergência da oferta de PICS na ESF. Os municípios com maior convergência na oferta são de pequeno porte populacional e com maior cobertura de atenção básica. A pequena quantidade de municípios com oferta reconhecida por gestores e profissionais reforça o pressuposto de que são os profissionais os principais responsáveis pela expansão das PICS no SUS, em detrimento de iniciativas da gestão. Esse cenário caracteriza a necessidade de apropriação por parte dos gestores do que é desenvolvido na ESF, para o fortalecimento das PICS e a mobilização de recursos institucionais para sua manutenção e ampliação.

El artículo presenta un análisis de la oferta de Prácticas Integradoras y Complementarias en Salud (PICS), dentro la Estrategia Salud de la Familia (ESF), a partir de la convergencia en la respuesta de gestores y profesionales. Se trata de una investigación cuantitativa descriptiva-exploratoria, utilizando dos bancos de datos: la Encuesta Nacional de Prácticas Integradoras y Complementarias de Salud en el SUS y el Programa Nacional de Mejora de Acceso y Calidad de la Atención Básica (PMAQ). De acuerdo con los gestores, la oferta de PICS estuvo presente en la ESF de un 26,7% de los municipios participantes en la Encuesta Nacional y en un 25,5% de los municipios del PMAQ, según los profesionales. De los 1.478 municipios que participaron en las dos investigaciones, en un 8,6% de ellos hubo convergencia de la oferta de PICS en la ESF. Los municipios con mayor convergencia en la oferta son de pequeño porte poblacional y con mayor cobertura de atención básica. La pequeña cantidad de municipios con oferta reconocida por gestores y profesionales refuerza la presuposición de que son los profesionales los principales responsables de la expansión de las PICS en el SUS, en detrimento de iniciativas de la gestión. Este escenario caracteriza la necesidad de apropiación por parte de los gestores de lo que se desarrolla en la ESF, para el fortalecimiento de las PICS y la movilización de recursos institucionales para su mantenimiento y ampliación.

Reflexos do pagamento por desempenho na atuação do(a)s profissionais da Atenção Primária à Saúde, Paraíba, Brasil / Effects of pay-for-performance on the work of primary health care professionals in the state of Paraíba, Brazil / Reflejos del pago por desempeño en la actuación de los y las profesionales de la atención primaria de la salud, Paraíba, Brasil

O estudo buscou compreender a influência da estratégia do Pay for Performance (P4P), por meio do Programa Nacional de Melhoria do Acesso e Qualidade da Atenção Básica (PMAQ-AB), na atuação do(a)s trabalhadore(a)s. Trata-se de um estudo de caso qualitativo realizado com o(a)s trabalhadore(a)s das Estratégias de Saúde da Família. A análise foi realizada mediante a técnica de construção de narrativas. Constatou-se que o P4P contribuiu para qualificação do processo de trabalho, ao mesmo tempo que estimulou competição e conflito entre as equipes, aflorando sentimentos de culpa e injustiça e, devido à precarização do trabalho, o estímulo financeiro se descaracteriza, tornando-se complemento salarial. Problemas macroestruturais afetam as condições de trabalho e a motivação do(a)s trabalhadore(a)s, de modo que modelos de incentivo financeiro, isoladamente, não são suficientes para reverter tal cenário.

This study sought to understand the influence of pay-for-performance (P4P) on worker performance using data from the National Program for Improving Primary Care Access and Quality (PMAQ-AB). We conducted a qualitative case study with professionals working in family health strategy teams. The data were analyzed using the narrative construction technique. The findings show that P4P contributed to the improvement of work processes, while at the same time stimulating competition and conflict between the teams, causing feelings of guilt and injustice. However, the original purpose of the financial incentive is defeated due to poor working terms and conditions, becoming akin to a salary supplement. Macrostructural problems affect working conditions and worker motivation, showing that financial incentive models alone are not sufficient to reverse this situation.

El estudio buscó comprender la influencia de la estrategia Pay for Performance (P4P), por medio del Programa de Mejora del Acceso y Calidad de la Atención Básica (Pmaq-AB), en la actuación de los trabajadores y las trabajadoras. Se trata de un estudio de caso, cualitativo, realizado con los trabajadores y las trabajadoras de las Estrategias de Salud de la Familia. El análisis se realizó mediante la construcción de narrativas. Se constató que el P4P contribuyó para la calificación del proceso de trabajo, al mismo tiempo que incentivó competencia y conflicto entre los equipos, haciendo aflorar los sentimientos de culpa e injusticia y, debido a la precarización del trabajo, el incentivo financiero se descaracteriza pasando a ser complemento salarial. Problemas macroestructurales afectan las condiciones de trabajo y la motivación de los trabajadores y de las trabajadoras, de modo que los modelos de incentivo económico, aisladamente, no son suficientes para revertir ese escenario.

Conflito distributivo: análise do Programa de Melhoria do Acesso e Qualidade da Atenção Básica (PMAQ-AB) em duas capitais nordestinas / Conflicto distributivo: análisis del Programa de Mejora del Acceso y Calidad de la Atención Básica (PMAQ-AB) en dos capitales del nordeste de Brasil / Distributive conflict: analysis of the Program for Improving Access and Quality of Primary Care (PMAQ-AB) in two Brazilian northeastern capitals

Este artigo analisa a execução do PMAQ-AB a partir de sua contextualização em um cenário político nacional de profundas transformações, desde o reformismo fraco que promoveu lenta extensão de direitos até o contrarreformismo forte da restauração neoliberal. Para debater os elementos relacionados ao trabalho e às disputas pela distribuição dos recursos públicos, foi realizado estudo de caso com trabalhadores, gestores e conselheiros de saúde em duas capitais do nordeste brasileiro. Os resultados evidenciam o acirramento do conflito distributivo e o resultado desfavorável aos trabalhadores no contexto pós-golpe parlamentar de 2016. As dinâmicas locais expõem processos de contração salarial e individualização das relações de trabalho e a reafirmação da meritocracia como justificativa ideológica da precarização. A isso, trabalhadores se contrapõem pela reafirmação de sua condição coletiva de classe, em favor de benefícios derivados do PMAQ, como recomposição salarial para todos.(AU)

Este artículo analiza la realización del PMAQ-AB a partir de su contextualización en un escenario político nacional de profundas transformaciones, desde el reformismo débil que promovió una lenta extensión de derechos contra el reformismo fuerte de la restauración neoliberal. Para discutir los elementos relacionados al trabajo y a las disputas por la distribución en los recursos públicos se realizó un estudio de caso con trabajadores, gestores y consejeros de salud en dos capitales del nordeste brasileño. Los resultados ponen en evidencia el recrudecimiento del conflicto distributivo y el resultado desfavorable para los trabajadores en el contexto post-golpe parlamentario de 2016. Las dinámicas locales exponen procesos de contracción salarial e individualización de las relaciones de trabajo y la reafirmación de la meritocracia como justificativa ideológica de la precarización. A eso se contraponen los trabajadores por medio de la reafirmación de su condición colectiva de clase, en favor del beneficio derivado del PMAQ con la recomposición salarial para todos.(AU)

This article analyzes the implementation of the Program for Improving Access and Quality of Primary Care (PMAQ-AB) in the context of a national political scenario of deep transformations, from the weak reformism that promoted slow extension of rights to the strong counter-reformism of neoliberal restoration. It is a case study with health workers, managers, and counselors in two capital cities in northeastern Brazil, discussing matters of work and distributive disputes of public resources. Results show the intensification of these conflicts in health and the unfavorable outcome for workers after the parliamentary coup in 2016 political context. Local dynamics expose the wage contraction and individualization of labor relations and the reassertion of meritocracy as an ideological ground for precariousness. Workers oppose this, reaffirming their collective class condition, favoring the benefit derived from PMAQ for fully regaining their group wages.(AU)

Lesão Miocárdica e Prognóstico em Pacientes Hospitalizados com COVID-19 no Brasil: Resultados do Registro Nacional de COVID-19 / Myocardial Injury and Prognosis in Hospitalized COVID-19 Patients in Brazil: Results From The Brazilian COVID-19 Registry

Resumo Fundamento As complicações cardiovasculares da COVID-19 são aspectos importantes da patogênese e do prognóstico da doença. Evidências do papel prognóstico da troponina e da lesão miocárdica em pacientes hospitalizados com COVID-19 na América Latina são ainda escassos. Objetivos Avaliar a lesão miocárdica como preditor independente de mortalidade hospitalar e suporte ventilatório mecânico em pacientes hospitalizados, do registro brasileiro de COVID-19. Métodos Este estudo coorte é um subestudo do registro brasileiro de COVID-19, conduzido em 31 hospitais brasileiros de 17 cidades, de março a setembro de 2020. Os desfechos primários incluíram mortalidade hospitalar e suporte ventilatório mecânico invasivo. Os modelos para os desfechos primários foram estimados por regressão de Poisson com variância robusta, com significância estatística de p<0,05. Resultados Dos 2925 pacientes [idade mediana de 60 anos (48-71), 57,1%], 27,3% apresentaram lesão miocárdica. A proporção de pacientes com comorbidades foi maior nos pacientes com lesão miocárdica [mediana 2 (1-2) vs. 1 (0-20)]. Os pacientes com lesão miocárdica apresentaram maiores valores medianos de peptídeo natriurético cerebral, lactato desidrogenase, creatina fosfoquinase, N-terminal do pró-peptídeo natriurético tipo B e proteína C reativa em comparação a pacientes sem lesão miocárdica. Como fatores independentes, proteína C reativa e contagem de plaquetas foram relacionados com o risco de morte, e neutrófilos e contagem de plaquetas foram relacionados ao risco de suporte ventilatório mecânico invasivo. Os pacientes com níveis elevados de troponina apresentaram um maior risco de morte (RR 2,03, IC95% 1,60-2,58) e suporte ventilatório mecânico (RR 1,87;IC95% 1,57-2,23), em comparação àqueles com níveis de troponina normais. Conclusão Lesão cardíaca foi um preditor independente de mortalidade hospitalar e necessidade de suporte ventilatório mecânico em pacientes hospitalizados com COVID-19.

Abstract Background Cardiovascular complications of COVID-19 are important aspects of the disease's pathogenesis and prognosis. Evidence on the prognostic role of troponin and myocardial injury in Latin American hospitalized COVID-19 patients is still scarce. Objectives To evaluate myocardial injury as independent predictor of in-hospital mortality and invasive mechanical ventilation support in hospitalized patients, from the Brazilian COVID-19 Registry. Methods This cohort study is a substudy of the Brazilian COVID-19 Registry, conducted in 31 Brazilian hospitals of 17 cities, March-September 2020. Primary outcomes included in-hospital mortality and invasive mechanical ventilation support. Models for the primary outcomes were estimated by Poisson regression with robust variance, with statistical significance of p<0.05. Results Of 2,925 patients (median age of 60 years [48-71], 57.1% men), 27.3% presented myocardial injury. The proportion of patients with comorbidities was higher among patients with cardiac injury (median 2 [1-2] vs. 1 [0-2]). Patients with myocardial injury had higher median levels of brain natriuretic peptide, lactate dehydrogenase, creatine phosphokinase, N-terminal pro-brain natriuretic peptide, and C-reactive protein than patients without myocardial injury. As independent predictors, C-reactive protein and platelet counts were related to the risk of death, and neutrophils and platelet counts were related to the risk of invasive mechanical ventilation support. Patients with high troponin levels presented a higher risk of death (RR 2.03, 95% CI 1.60-2.58) and invasive mechanical ventilation support (RR 1.87, 95% CI 1.57-2.23), when compared to those with normal troponin levels. Conclusion Cardiac injury was an independent predictor of in-hospital mortality and the need for invasive mechanical ventilation support in hospitalized COVID-19 patients.

Economic growth and inflation rate: implications for municipal revenue and health expenditure of the municipalities of Pernambuco, Brazil. / Crescimento econômico e taxa de inflação: implicações na receita municipal e na despesa com saúde dos municípios de Pernambuco, Brasil.

This paper analyzes the implications of municipal budget revenue growth and the monetary policy's inflation rates goals in the availability of public health resources of municipalities. This is a descriptive, exploratory, quantitative, retrospective and longitudinal cross-sectional study covering the period 2002-2011. We analyzed health financing and expenditure variables in the municipalities of the state of Pernambuco, Brazil, describing the trend and the relationship between them. Data showed the growth of the variables and trend towards homogeneity. The exception was for the participation of Intergovernmental Transfers in the Total Health Expenditure of the Municipality. We found a significant correlation between Budget Revenue per capita and Health Expenditure per capita and a strong significant negative correlation between Inflation Rate, Budget Revenue per capita and Health Expenditure per capita. We concluded that increased health expenditure is due more to higher municipal tax revenue than to increased transfers that, in relative terms, did not increase. The strong inverse relationship between inflation rate and the Financing and Expenditure variables show that the monetary policy's inflation goals have restricted health financing to municipalities.

Interface Regionalização e Controle Social numa Macrorregião de Saúde

Objetivo: analisar a participação do controle social no processo de regionalização da saúde nos municípios sede de macrorregião em Pernambuco. Método: foi realizado um estudo de caso, de abordagem qualitativa. Os dados foram obtidos mediante entrevistas semiestruturada com doze conselheiros municipais de saúde e de análise documental dos relatórios das conferências municipais de saúde e das atas, resoluções e listas de frequência das reuniões das Comissões Intergestores Regional. A identificação das dimensões foi realizada mediante análise temática. Resultados: evidenciou-se o conhecimento incipiente dos conselheiros em relação aos aspectos conceituais, à sua atuação no processo de regionalização e, principalmente, aos instrumentos de planejamento regional. A ausência de espaços institucionalizados de controle social no âmbito regional de caráter regular e permanente, como fóruns, conferências e conselhos regionais e de representantes dos conselhos na Comissões Intergestores Regional repercutem nas escassas discussões acerca da regionalização. Conclusão: há necessidade de promover o empoderamento dos conselheiros com o objetivo de fortalecer o processo de regionalização.

Life stories of elderly women with cervical cancer: a look beyond getting sick / Histórias de vida de mulheres idosas com câncer de colo do útero: um olhar para além do adoecer

Abstract Chronic degenerative illnesses have currently taken on a great predominance at the epidemiological profile, by affecting specially the elderly population. Among such diseases, Cancer has been studied through the broadening of information, which brought scientific advancement for the disease care. However, such topics constantly focus on statistic data, setting the lifetime story of those people aside. This paper aimed at understanding the process of sickness among elderly women and its development up to the diagnostics of uterus cancer through getting closer to their lifetime stories. It is about a qualitative research whose methodology used was that of life history. The methodological choice aimed at providing an intersection in the lives of different women, giving visibility to their memories. Five elderly women between 62 and 89 years old participated in the research, which turns into distinctive lifetime stories, with their singularities, though they interweave before the hard reality faced by them along their aging. Their relationship with their getting-sick development is surrounded by fear into different ways. It is necessary, therefore, to look to the elderly women uniquely, regarding the social relations that interfere during their lives and determine their aging.

Resumo As doenças crônico-degenerativas assumem grande predominância no perfil epidemiológico, acometendo a população idosa. Entre essas doenças, o câncer tem sido estudado, ampliando as informações e trazendo avanço científico no cuidado à doença, contudo, as publicações constantemente centram-se nos dados estatísticos, deixando de lado a história de vida dessa população. O presente artigo objetivou compreender a relação com o processo de adoecimento de mulheres idosas em seguimento para o câncer do colo do útero, por meio da aproximação com as suas histórias de vida. Trata-se de um estudo qualitativo, cujo método utilizado foi o da história de vida. A escolha metodológica visou proporcionar um encontro com a vida de diferentes mulheres, dando visibilidade às suas memórias. Participaram da pesquisa cinco mulheres idosas com idade entre 62-89 anos, resultando em diferentes histórias de vida, com suas singularidades, mas que se entremeiam diante da dura realidade enfrentada por elas ao longo de seu processo de envelhecimento. A relação delas com o processo de adoecimento é permeada pelo medo em diferentes dimensões. Conclui-se que há necessidade de um olhar diferenciado para a mulher idosa, considerando as relações sociais que interferem no curso de sua vida e determinam a sua velhice.

The Mais Médicos (More Doctors) Program in Northeast: evaluation of hospitalizations for Primary Healthcare-sensitive conditions. / Programa Mais Médicos no Nordeste: avaliação das internações por condições sensíveis à Atenção Primária à Saúde.

This paper analyzes the increase in professionals in Brazil's Northeastern Region resulting from the Mais Médicos (More Doctors) Program. The scale of the increase was analyzed through the indicator Hospitalizations for Primary-Care Sensitive Conditions (HPSCs). The method used was a quantitative approach, based on data on distribution of doctors and service they provided in these states, and on hospitalizations for diarrhea and gastroenteritis in the period September 2012 to August 2015. The choice of this condition took into account the aspects of: its high frequency in the period; the simplicity of intervention; and its historic occurrence in the Northeast. The results show that the Mais Médicos Program had an influence on the reduction of hospitalizations for this type of condition - they fell by 35% in the period investigated, with important differences between the states. In spite of the significant scale of the entry of medical professionals into the health system, it is known that in isolation simply increasing the number of professionals of a particular type has a limited effect in improving primary healthcare.

Characteristics of the distribution of doctors in the Mais Médicos (More Doctors) Program in the states of Brazil's Northeast. / Características da distribuição de profissionais do Programa Mais Médicos nos estados do Nordeste, Brasil.

Inequalities in access to health, reflecting shortages and inadequate geographical distribution of health professionals, have been indicated as a challenge for Brazil. This paper analyzes the geographical distribution of professionals of the Mais Médicos Program allocated in the Northeastern Region of Brazil, through a descriptive cross-sectional study. Secondary data provided by the Health Ministry were used, and thematic maps of distribution of doctors in the Region were prepared. Data on 4,716 doctors who became members of health teams in 1,294 municipalities in six Indigenous Health Districts in the years 2013 and 2014 were analyzed. The greater part of the municipalities of the Region received between one and five doctors. The municipalities most benefited had, at least, 20% of their population in extreme poverty. 99.9% of the doctors were allocated in a Health Center or Primary Healthcare Unit. The majority were women (57%), predominantly of the 45-49 age group (24%). In spite of the advances achieved by the Program - such as distribution of the doctors in locations with greater vulnerability - some States continue to have significant shortages of healthcare.