Crise global da atenção primária à saúde / Global crisis in primary health care / Crisis global de la atención primaria

Enquanto no Norte Global se discute uma crise na Atenção Primária à Saúde, a maioria dos países nunca chegou a constituir sistemas de saúde baseados propriamente numa atenção primária robusta. Nesse cenário, o Brasil apresenta uma tendência mais favorável, com conquistas importantes para a atenção primária e a medicina de família e comunidade nos últimos dez anos. Restam desafios a serem superados para que o Sistema Único de Saúde alcance níveis satisfatórios de acesso a seus serviços, com profissionais adequadamente formados e valorizados pela população.

While the Global North is discussing a crisis in primary health care, the majority of countries have never managed to establish health systems based on robust primary care. Brazil presents a more favorable trend, with important achievements for primary care and family practice over the last ten years. There are still challenges to be overcome so that the Unified Health System achieves satisfactory levels of access to its services, with professionals who are properly trained and valued by the public.

Mientras que en el Norte Global se habla de una crisis de la atención primaria, la mayoría de los países nunca han creado realmente sistemas sanitarios basados en una atención primaria robusta. Brasil, muestra una tendencia más favorable, con importantes logros para la atención primaria y la medicina familiar y comunitaria en los últimos diez años. Aún quedan retos por superar para que el Sistema Único de Salud alcance niveles satisfactorios de acceso a sus servicios, con profesionales debidamente formados y valorados por la población.

Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders guidelines for the treatment of adult obsessive-compulsive disorder. Part II: cognitive-behavioral therapy

Objectives: To summarize evidence-based cognitive-behavioral therapy (CBT) treatment and propose clinical interventions for adult patients with obsessive-compulsive disorder (OCD). Methods: The literature on CBT interventions for adult OCD, including BT and exposure and response prevention, was systematically reviewed to develop updated clinical guidelines for clinicians, providing comprehensive details about the necessary procedures for the CBT protocol. We searched the literature from 2013-2020 in five databases (PubMed, Cochrane, Embase, PsycINFO, and Lilacs) regarding study design, primary outcome measures, publication type, and language. Selected articles were assessed for quality with validated tools. Treatment recommendations were classified according to levels of evidence developed by the American College of Cardiology and the American Heart Association. Results: We examined 44 new studies used to update the 2013 American Psychiatric Association guidelines. High-quality evidence supports CBT with exposure and response prevention techniques as a first-line treatment for OCD. Protocols for Internet-delivered CBT have also proven efficacious for adults with OCD. Conclusion: High-quality scientific evidence supports the use of CBT with exposure and response prevention to treat adults with OCD.

Animal hoarding: a systematic review

Objectives: Animal hoarding is a special manifestation of hoarding disorder, characterized by the accumulation of animals and failure to provide them with minimal care. The main objective of this systematic review is to evaluate the characteristics of animal hoarding, focusing on the profile of affected individuals and the features of accumulation behavior. Methods: A systematic search of the literature was conducted in the electronic databases MEDLINE, Scopus, and LILACS until October 2022. We included case series (n ≥ 10) and cross-sectional studies assessing animal hoarding. Results: A total of 374 studies were initially retrieved. Most studies were classified as having poor quality and significant risk of bias. A total of 538 individuals with animal hoarding were evaluated. These individuals were predominantly middle-aged, unmarried women who lived alone in urban areas. Most of their residences had unsanitary conditions. Recidivism rates varied from 13-41%. Cats and dogs were the main hoarded species, mostly acquired through unplanned breeding, and disease, injury, behavioral problems, and a lack of hygiene were characreristic of their condition. Animal carcasses were found in up to 60% of the properties. Conclusion: Animal hoarding is a complex condition that requires urgent attention. More research is necessary to develop effective strategies that can save community resources, improve animal and human welfare, and prevent recidivism.

Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders guidelines for the treatment of adult obsessive-compulsive disorder. Part I: pharmacological treatment

Objectives: To summarize evidence-based pharmacological treatments and provide guidance on clinical interventions for adult patients with obsessive-compulsive disorder (OCD). Methods: The American Psychiatric Association (APA) guidelines for the treatment of OCD (2013) were updated with a systematic review assessing the efficacy of pharmacological treatments for adult OCD, comprising monotherapy with selective serotonin reuptake inhibitors (SSRIs), clomipramine, serotonin and norepinephrine reuptake inhibitors (SNRIs), and augmentation strategies with clomipramine, antipsychotics, and glutamate-modulating agents. We searched for the literature published from 2013-2020 in five databases, considering the design of the study, primary outcome measures, types of publication, and language. Selected articles had their quality assessed with validated tools. Treatment recommendations were classified according to levels of evidence developed by the American College of Cardiology and the American Heart Association (ACC/AHA). Results: We examined 57 new studies to update the 2013 APA guidelines. High-quality evidence supports SSRIs for first-line pharmacological treatment of OCD. Moreover, augmentation of SSRIs with antipsychotics (risperidone, aripiprazole) is the most evidence-based pharmacological intervention for SSRI-resistant OCD. Conclusion: SSRIs, in the highest recommended or tolerable doses for 8-12 weeks, remain the first-line treatment for adult OCD. Optimal augmentation strategies for SSRI-resistant OCD include low doses of risperidone or aripiprazole. Pharmacological treatments considered ineffective or potentially harmful, such as monotherapy with antipsychotics or augmentation with ketamine, lamotrigine, or N-acetylcysteine, have also been detailed.

Factor structure of the Dimensional Yale-Brown Obsessive-Compulsive Scale in a large sample of adults with obsessive-compulsive disorder

Objectives: Although the Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) is a widely used instrument for assessing different obsessive-compulsive symptom dimensions, its factor structure has never been studied in a Brazilian population. Thus, we aimed to assess the goodness-of-fit indexes and factor loadings of two higher-order models of the DY-BOCS using confirmatory factor analysis (CFA) in a large obsessive-compulsive disorder (OCD) sample. Methods: We tested two CFA models in a sample of 955 adults with OCD who had been assessed with the DY-BOCS in a cross-sectional multi-site study. The first model encompassed the symptom checklist (present or absent), whereas the second focused on items related to severity scores. Results: Both models presented adequate goodness-of-fit indexes. The comparative fit index, Tucker-Lewis index, and omega were > 0.9, while the root mean square error of approximation was ≤ 0.06 for both models. Factor loadings for each item of each dimension are presented and discussed. Conclusion: Higher-order factor models showed adequate goodness-of-fit indexes, indicating that they appropriately measured OCD dimensions in this Brazilian population.

Lifestyle Interventions in the Treatment of Obsessive-Compulsive and Related Disorders: A Systematic Review.

OBJECTIVE: Lifestyle medicine is increasingly important in psychiatry for its efficacy as a transdiagnostic treatment, its preventative potential, and its increased tolerability compared with first-line strategies. Although the impact of lifestyle medicine is strong across many psychiatric illnesses, our understanding of the effectiveness of lifestyle interventions in treating obsessive-compulsive and related disorders (OCRDs) is minimal. We aimed to conduct a systematic review examining the effect of lifestyle interventions (targeting diet, exercise, sleep, stress management, and tobacco/alcohol use) on OCRD symptoms. METHODS: We systematically searched four electronic databases for published randomized controlled trials reporting on lifestyle interventions for OCRDs. We qualitatively synthesized results of eligible studies and calculated mean changes in symptom severity from baseline to end point and standardized between-group effect sizes. RESULTS: We identified 33 eligible studies. Poor efficacy was noted across a number of rigorous dietary supplement interventions with some promising data in four (of six) studies regarding N-acetylcysteine for trichotillomania, skin picking, and obsessive-compulsive disorder. Stress management interventions, generally characterized by high risk of bias, reported mild effectiveness with greater effects noted for mind-body exercises (yoga) for obsessive-compulsive disorder. Greater improvements may be achieved when lifestyle intervention is adjunct to first-line treatments and delivered by facilitators. CONCLUSIONS: Diet (particularly N-acetylcysteine) and stress management interventions seem promising avenues for OCRDs treatment. We present an action plan to move the lifestyle interventions for OCRDs field forward. Further high-quality lifestyle interventions are required to improve the certainty of findings and to inform clinical treatment guidelines.Review Registration Number: CRD42020151407.

PTSD Predicts Smoking Cessation Failure in a Trauma-Exposed Population.

OBJECTIVE: The objective of the study was to investigate whether a diagnosis of posttraumatic stress disorder (PTSD; full or partial) or specific PTSD symptom clusters predicted failure in quitting smoking in a trauma-exposed population. Methods: Participants were 310 smokers who attempted quitting smoking, either successfully (quitters, n = 213) or not (relapsers, n = 97), who lived in slums and were attending a family doctor program. Measurements included a general questionnaire covering sociodemographic characteristics, clinical status and life habits, and the Posttraumatic Stress Disorder Checklist - Civilian Version. Differences in sociodemographic, clinical and lifestyle characteristics between quitters and relapsers were compared using a chi-square test. Because of the small sample size, full and partial PTSD were collapsed into a single category. Results: Significant differences (p ≤ .15) between quitters and relapsers were found in age, body mass index (BMI), income, alcohol consumption, and in the presence of full/partial PTSD diagnosis and of all three symptom clusters separately. Four logistic regression models predicting smoking cessation were modeled to control for confounding factors and included as independent variables a full/partial PTSD diagnosis and the three posttraumatic symptom clusters. The avoidance/numbing cluster presented the strongest association with relapse status (ORa 2.04, 95% CI [1.15, 3.63], p = .015), followed by the full/partial PTSD (ORa 1.80, 95% CI [1.04, 3.14], p = .038). The re-experiencing and the hyperarousal clusters were non-significantly associated with smoking cessation (ORa 1.34, 95% CI [0.80, 2.31], ns and ORa 1.65, 95% CI [0.96, 2.84], ns, respectively). Conclusions: Full/partial PTSD and posttraumatic symptom clusters uniquely predict risk for smoking relapse and thus may be a useful therapeutic target in trauma-exposed smokers.

Pesquisar para quê? / Research for what? / ¿Investigar para qué?

Para contribuir com a atenção primária à saúde, a pesquisa em medicina de família e comunidade precisa evitar quatro fatores que têm levado ao desperdício da pesquisa biomédica em nível mundial: questões de pesquisa irrelevantes; métodos inadequados para alcançar os objetivos da pesquisa; lentidão e inadequação da publicação dos resultados; relato da pesquisa obscuro e pouco transparente. Neste editorial, introduzimos medidas para os autores garantirem o impacto de sua pesquisa, e apresentamos novas políticas editoriais da RBMFC.

To contribute to primary health care, research in family and community medicine needs to avoid four factors that have led to wasted biomedical research worldwide: irrelevant research questions; inadequate methods to achieve the research objectives; slow and inadequate publication of results; obscure and not transparent reporting. In this editorial, we introduce measures for authors to ensure the impact of their research, and new editorial policies from RBMFC.

Para contribuir a la atención primaria de salud, la investigación en medicina familiar y comunitaria debe evitar cuatro factores que han llevado a la pérdida de investigación biomédica en todo el mundo: preguntas de investigación irrelevantes; métodos inadecuados para lograr los objetivos de investigación; lentitud y publicación inadecuada de resultados; oscuridad e falta de transparencia del informe de investigación. En este editorial, presentamos medidas para que los autores garanticen el impacto de su investigación, y presentamos nuevas políticas editoriales de RBMFC.

Agradecimento aos Revisores da RBMFC em 2020 / Acknowledgment of all those who reviewed for RBMFC in 2020 / Reconocimiento a los revisores de la RBMFC en 2020

A Revista Brasileira de Medicina de Família e Comunidade (RBMFC) agradece aos Avaliadores listados abaixo que atuaram como revisores ad hoc durante o ano de 2020, dedicando horas voluntariamente para a emissão de pareceres técnicos sobre manuscritos submhttps://fi-admin.bvsalud.org/utils/field_assist/abstract/#etidos a esta revista.

Acesso aberto a artigos, dados e materiais de pesquisa na RBMFC / Open access to articles, data and research materials on RBMFC / Acceso abierto a artículos, datos y materiales de investigación en RBMFC

Acesso aberto aos artigos, dados e materiais de pesquisa são alguns elementos-chave da ciência aberta, um movimento plural que visa a transformar a criação e a comunicação do conhecimento científico. Graças à publicação de artigos em acesso aberto e à adoção de boas práticas editoriais, a RBMFC tem seus artigos indexados na LILACS e, mais recentemente, no DOAJ. A RBMFC também adota as diretrizes Transparency and Openness Promotion do Center for Open Science, e disponibiliza suas referências na CrossRef em domínio público, graças ao que a revista foi incluída no índice de citações OpenCitations. Com isso, a RBMFC espera tornar mais acessível, democrática e eficiente a pesquisa em medicina de família e comunidade e atenção primária à saúde.

Open access to research articles, data and materials are some key elements of open science, a plural movement that aims to transform the creation and communication of scientific knowledge. Thanks to the publication of articles in open access and the adoption of good editorial practices, RBMFC has its articles indexed in LILACS and, more recently, in DOAJ. RBMFC also adopts the Transparency and Openness Promotion guidelines from the Center for Open Science, and makes its references in CrossRef available in the public domain, thanks to which the journal was included in the OpenCitations citation index. With this, RBMFC hopes to make research in family and community medicine and primary health care more accessible, democratic and efficient

El acceso abierto a artículos, datos y materiales de investigación son algunos de los elementos clave de la ciencia abierta, un movimiento plural que tiene como objetivo transformar la creación y comunicación del conocimiento científico. Gracias a la publicación de artículos en acceso abierto y la adopción de buenas prácticas editoriales, RBMFC tiene sus artículos indexados en LILACS y, más recientemente, en DOAJ. RBMFC también adopta las directrices Transparency and Openness Promotion del Center for Open Science, y hace que sus referencias en CrossRef estén disponibles en el dominio público, gracias a lo cual la revista fue incluida en el índice de citas de OpenCitations. Con esto, RBMFC espera que la investigación en medicina familiar y comunitaria y atención primaria de salud sea más accesible, democrática y eficiente.

Utilization of the Brazilian public health system by privately insured individuals: a literature review.

More than one in four Brazilians have private health insurance (PHI), even thought it covers mostly the same procedures as the Brazilian Unified National Health System (SUS). This literature review included articles and monographs published since 1990 about the utilization of SUS by privately insured individuals. Considering outpatient care and hospitalization, privately insured people in Brazil use SUS in approximately 13% of the times they receive health care, and approximately 7% of people receiving care paid by SUS are privately insured; these findings vary depending on the type of service studied and on study methods. Utilization of SUS is more frequent in less developed regions, by people with more restricted PHI plans and by people with worse health status. Privately insured people report the limitations of PHI plans as their reasons for resorting to SUS. Sometimes, beneficiaries of PHI plans owned by nonprofit hospitals (which also provide health care financed by SUS) have easier access to care than uninsured people financed by SUS. Anecdotally, privately insured people are satisfied with SUS, but not to the point of adopting SUS as their preferred source of care. In short, for privately insured people, SUS only plays a secondary role in their health care. Despite PHI taking over part of the SUS's health care demand, PHI represents a restriction of the universal, equitable character of the SUS.

Renovação das práticas editoriais e instruções aos autores da RBMFC a partir de 2019 / Renewal of editorial practices and author guidelines to RBMFC authors from 2019 / Renovación de las prácticas editoriales y directrices para autores de RBMFC a partir de 2019

Neste editorial, são apresentadas as novas práticas editoriais e instruções aos autores que nortearão a Revista Brasileira de Medicina de Família e Comunidade (RBMFC) a partir de 2019. Com elas, a RBMFC renova seu compromisso com a publicação de trabalhos acadêmicos de qualidade para médicos de família e comunidade e outros profissionais da Atenção Primária à Saúde, contribuindo para a melhoria do cuidado à população.

This editorial presents the new editorial practices and author guidelines for Revista Brasileira de Medicina de Família e Comunidade (Brazilian Journal of Family and Community Medicine ­ RBMFC) starting in 2019. With them, RBMFC renews its commitment to publishing quality academic papers for family and community physicians and other primary care practitioners, contributing to the improvement of health care.

Este editorial presenta las nuevas prácticas editoriales y las directrices para autores para la Revista Brasileira de Medicina de Família e Comunidade (Revista Brasileña de Medicina Familiar y Comunitaria ­ RBMFC) a partir de 2019. Con ellas, RBMFC renueva su compromiso de publicar documentos académicos de calidad para los médicos de familia y comunidad y otros profesionales de atención primaria, contribuyendo para la mejora de la atención de salud.

Diversidade e Direitos Humanos na Atenção Primária à Saúde / Diversidade e Direitos Humanos na Atenção Primária à Saúde / Diversidad y derechos humanos en la atención primaria de salud

Neste editorial, apresenta-se o resultado da chamada pública de artigos que compõem o especial "Diversidade e Direitos Humanos na Atenção Primária à Saúde".A situação dos direitos humanos no Brasil é preocupante, existindo profundas desigualdades no exercício pleno da cidadania entre grupos sociais, o que inclui o acesso a serviços de saúde e manutenção de níveis de saúde adequados e justos. Questões raciais, de gênero, sexualidade, diversidade, violência e direitos humanos ganham cada vez mais importância no contexto da atenção primária à saúde (APS) e da Medicina de Família e Comunidade (MFC). Os trabalhos publicados neste especial apontam para a importância de pensarmos a organização de uma APS interseccional e uma prática em saúde abrangente, acolhedora, humanizada, resolutiva e culturalmente e socialmente orientada. Sugere-se que a MFC precisa produzir reflexões teóricas mais robustas para subsidiar o cuidado a pessoas em graves situações de vulnerabilidade e sofrimento. Aponta-se ainda para a necessária equidade de gênero, etnia e territorial na composição do corpo editorial da RBMFC. Espera-se que o conteúdo deste especial apoie a reflexão e a construção de práticas e de políticas que consigam enfrentar o quadro das profundas e diversas desigualdades sociais do país, e que no futuro possamos contar com uma maior produção de conhecimento neste campo.

This editorial presents the result of the public call for articles that make up the special "Diversity and Human Rights in Primary Health Care". The human rights situation in Brazil is worrying, with profound inequities in the full exercise of citizenship among social groups, including access to health services and maintenance of adequate and fair health levels. Racial, gender, sexuality, diversity, violence and human rights are becoming increasingly important in the context of primary health care (PHC) and Family and Community Medicine.The works published in this special point to the importance of thinking about the organization of an intersectional PHC and a comprehensive, welcoming, humanized, resolute and culturally and socially oriented health practice. Family and Community Medicine should produce more robust theoretical reflections to support care for people in severe situations of vulnerability and suffering. At the same time, the composition of RBMFC's editorial board should have greater equity in gender, ethnicity and geography. We hope the content of this special will support the reflection on and construction of practices and policies able to face the deep and diverse social inequalities of the country, and that in the future we can count on a greater knowledge production in this field.

Este editorial presenta el resultado de la convocatoria pública de artículos que componen el especial "Diversidad y derechos humanos en la atención primaria de salud". La situación de los derechos humanos en Brasil es preocupante, con profundas desigualdades en el ejercicio pleno de la ciudadanía entre los grupos sociales, incluido el acceso a los servicios de salud y el mantenimiento de niveles de salud adecuados y justos. Las cuestiones raciales, de género, sexualidad, diversidad, violencia y derechos humanos son cada vez más importantes en el contexto de la atención primaria de salud (APS) y la medicina de familia y comunidad (MFC). Los trabajos publicados en este especial señalan la importancia de pensar en la organización de una APS interseccional y una práctica de salud integral, acogedora, humanizada, resuelta y cultural y socialmente orientada. Se sugiere que la MFC necesita producir reflexiones teóricas más sólidas para apoyar la atención de personas en situaciones graves de vulnerabilidad y sufrimiento. También se señala la necesidad de igualdad de género, etnia y territorial en la composición del consejo editorial de RBMFC. Se espera que el contenido de este especial respalde la reflexión y la construcción de prácticas y políticas que puedan hacer frente a la imagen de las profundas y diversas desigualdades sociales del país, y que en el futuro podamos contar con una mayor producción de conocimiento en este campo.

Treatments used for obsessive-compulsive disorder-An international perspective.

OBJECTIVE: The objective of this study was to characterise international trends in the use of psychotropic medication, psychological therapies, and novel therapies used to treat obsessive-compulsive disorder (OCD). METHODS: Researchers in the field of OCD were invited to contribute summary statistics on the characteristics of their samples. Consistency of summary statistics across countries was evaluated. RESULTS: The study surveyed 19 expert centres from 15 countries (Argentina, Australia, Brazil, China, Germany, Greece, India, Italy, Japan, Mexico, Portugal, South Africa, Spain, the United Kingdom, and the United States) providing a total sample of 7,340 participants. Fluoxetine (n = 972; 13.2%) and fluvoxamine (n = 913; 12.4%) were the most commonly used selective serotonin reuptake inhibitor medications. Risperidone (n = 428; 7.3%) and aripiprazole (n = 415; 7.1%) were the most commonly used antipsychotic agents. Neurostimulation techniques such as transcranial magnetic stimulation, deep brain stimulation, gamma knife surgery, and psychosurgery were used in less than 1% of the sample. There was significant variation in the use and accessibility of exposure and response prevention for OCD. CONCLUSIONS: The variation between countries in treatments used for OCD needs further evaluation. Exposure and response prevention is not used as frequently as guidelines suggest and appears difficult to access in most countries. Updated treatment guidelines are recommended.

Gene variations in PBX1, LMX1A and SLITRK1 are associated with obsessive-compulsive disorder and its clinical features.

Genetic factors probably influence OCD development and a current hypothesis proposes that genes involved in the development of the central nervous system (CNS) are related to OCD. The aim of this study was to analyze six Single Nucleotide Polymorphisms (SNPs) in five genes with functions related to neurodevelopment in OCD. A total of 203 patient and 203 control samples were genotyped using the TaqMan® methodology. Statistically significant associations between OCD and PBX1 (rs2275558) in total sample (P = 0.002) and in males (P = 0.0003) were observed. Concerning symptom dimensions, the expression of neutralization showed a statistical significant association with LMX1A (rs4657411, P = 0.004) in total sample. We also observed significant association between LMX1A (rs4657411) and washing dimension in females (P = 0.01). Additionally, SLITRK1 (rs9593835) was significantly associated with checking dimension in male patients (P = 0.04). Our results indicate an important influence of neurodevelopment genes in the OCD susceptibility. Additional studies with larger samples are needed to confirm these results.

Utilization of the Brazilian public health system by privately insured individuals: a literature review / Utilização do sistema público de saúde brasileiro por usuários com planos de saúde privados: uma revisão da literatura / La utilización del sistema público de salud brasileño por la población asegurada por el sistema privado: una revisión de la literatura

Abstract: More than one in four Brazilians have private health insurance (PHI), even thought it covers mostly the same procedures as the Brazilian Unified National Health System (SUS). This literature review included articles and monographs published since 1990 about the utilization of SUS by privately insured individuals. Considering outpatient care and hospitalization, privately insured people in Brazil use SUS in approximately 13% of the times they receive health care, and approximately 7% of people receiving care paid by SUS are privately insured; these findings vary depending on the type of service studied and on study methods. Utilization of SUS is more frequent in less developed regions, by people with more restricted PHI plans and by people with worse health status. Privately insured people report the limitations of PHI plans as their reasons for resorting to SUS. Sometimes, beneficiaries of PHI plans owned by nonprofit hospitals (which also provide health care financed by SUS) have easier access to care than uninsured people financed by SUS. Anecdotally, privately insured people are satisfied with SUS, but not to the point of adopting SUS as their preferred source of care. In short, for privately insured people, SUS only plays a secondary role in their health care. Despite PHI taking over part of the SUS's health care demand, PHI represents a restriction of the universal, equitable character of the SUS.

Resumo: Mais de um em cada quatro brasileiros têm planos de saúde, apesar de estes planos cobrirem majoritariamente os mesmos procedimentos do Sistema Único de Saúde (SUS). Esta revisão da literatura incluiu artigos e monografias publicados desde 1990 sobre a utilização do SUS por indivíduos com plano de saúde. Ao considerar conjuntamente a assistência ambulatorial e hospitalar, os brasileiros com planos de saúde utilizam o SUS em aproximadamente 13% das vezes em que recebem cuidados; aproximadamente 7% das pessoas que recebem cuidados pagos pelo SUS dispõem de planos de saúde (os achados variam de acordo com o tipo de serviço analisado e com os detalhes metodológicos dos estudos). O aumento da utilização do SUS está associado a: regiões menos desenvolvidas do país, planos de saúde com pior cobertura e pessoas com pior saúde. Os brasileiros com plano de saúde citam as limitações dos planos como o motivo pelo qual recorrem ao SUS. Em alguns casos os beneficiários de planos de saúde comercializados por hospitais filantrópicos (os quais também prestam assistência financiada pelo SUS) relatam acesso mais fácil à assistência financiada pelo SUS, comparado com aqueles sem plano de saúde. Pessoas com plano de saúde eventualmente citam a satisfação com a utilização do SUS, mas não a ponto do SUS se tornar a fonte de assistência preferida. Em resumo, para os brasileiros com plano de saúde, o SUS desempenha papel secundário no financiamento dos cuidados de saúde. Embora os planos de saúde pareçam deslocar parte da demanda por assistência para fora do SUS, esses mesmos planos tendem a restringir o caráter universal e equitativo do SUS.

Resumen: Más de uno de cada cuatro brasileños tiene un seguro de salud privado (PHI), a pesar de que estos últimos cubren en su mayoría los mismos procedimientos que en el Sistema Unificado de Salud (SUS). Esta revisión de la literatura incluyó artículos y monografías publicadas desde 1990 sobre la utilización del SUS por parte de personas aseguradas mediante el sistema privado. Considerando atención ambulatoria junto a hospitalización, la población con seguro médico privado en Brasil utiliza el SUS aproximadamente un 13% de las veces que reciben atención médica; además, aproximadamente un 7% de la gente que recibe atención médica pagada a través del SUS tiene seguro privado. Los resultados varían con el tipo de servicio estudiado y con los detalles de los métodos de estudio. La frecuencia de utilización del SUS es mayor en las regiones menos desarrolladas, por parte de la población con planes de seguros de salud más limitados, y personas con peor salud. Las personas con seguros privados identifican las limitaciones de sus planes PHI como la razón por la que usan el SUS. Algunas veces, los beneficiarios de los planes PHI de hospitales sin fines de lucro (que también proveen servicios de salud financiados por el SUS) cuentan con un acceso más sencillo a los cuidados de salud sufragados por el SUS que las personas sin seguro. Anecdóticamente, la población con seguro de salud privado está satisfecha con la utilización que hacen del SUS, pero no hasta el extremo de que el SUS se trasforme en su principal vía para recibir servicios médicos. En resumen, para la población con seguro privado, el SUS juega un papel secundario en la financiación de la asistencia a sus cuidados de salud. Pese a que el PHI parece desviar del SUS parte de la demanda de cuidados de salud, el PHI representa una restricción del carácter universal y equitativo del SUS.

Panorama da expansão dos programas de Residência Médica em Medicina de Família e Comunidade no Brasil: desafios para sua consolidação / Expansion of the Family and Community Medicine Residency programs in Brazil: challenges for its consolidation / Panorama de la ampliación de los programas de Residencia Médica en Medicina de Familia y Comunidad en Brasil: desafíos para su consolidación

Este editorial tem como objetivo apresentar as principais conclusões dos artigos publicados no Especial Residência Médica pela Revista Brasileira de Medicina de Família e Comunidade em 2018. Tais artigos assinalam a importância da Residência Médica em Medicina de Família e Comunidade (RMMFC) na consolidação da Atenção Primária à Saúde no Brasil, trazendo significativas discussões sobre currículos baseados nas competências esperadas para o MFC, ferramentas de ensino-aprendizagem, política de preceptoria, desafios da política municipal e da organização das redes de atenção locais para o funcionamento do programa, sustentabilidade financeira da implementação da RMMFC, e propostas de novas áreas de atuação para a MFC. No geral, observa-se uma significativa expansão da RMMFC no país, sendo fundamental garantir maiores investimentos no fortalecimento da APS e da preceptoria com vistas a uma maior atratividade da área para os recém-formados. Sugere-se também uma contínua atualização das matrizes de competências esperadas para a MFC.(AU)

This editorial aims to present the main conclusions of the articles published in the Medical Residency Special Edition of the Brazilian Journal of Family and Community Medicine in 2018. These articles point to the importance of the Family and Community Medicine Residency (RMMFC) in the consolidation of Primary Health Care in Brazil, bringing significant discussions on competency-based curricula, teaching-learning tools, preceptorship policy, municipal policy challenges, organization of local health care networks, financial sustainability of the implementation of the RMMFC and proposals for new areas of actuation for the family physician. In the last years, there was a significant expansion of RMMFC in Brazil, being necessary greater investments in strengthening PHC, preceptorship and continuous update of the competency matrices expected for the Family and Community Medicine.(AU)

Este editorial tiene como objetivo presentar las principales conclusiones de los artículos publicados en el Especial Residencia Médica por la Revista Brasileña de Medicina de Familia y Comunidad en 2018. Tales artículos señalan la importancia de la Residencia Médica en Medicina de Familia y Comunidad (RMMFC) en la consolidación de la Atención Primaria a la salud en Brasil, trayendo significativas discusiones sobre currículos basados en las competencias, herramientas de enseñanza-aprendizaje, política de preceptoría, desafíos de la política municipal y de la organización de las redes de atención locales para el funcionamiento del programa, sostenibilidad financiera de la implementación de la RMMFC, y propuestas de nuevas áreas de actuación para la MFC. En general, se observa una significativa expansión de la RMMFC en el país, siendo fundamental mayores inversiones en el fortalecimiento de la APS y de la preceptoría con vistas a una mayor atracción del área para los recién formados. Se sugiere también una continua actualización de las matrices de competencias esperadas para la MFC.(AU)