Economic burden of colorectal and breast cancers attributable to lack of physical activity in Brazil.

BACKGROUND: The increasing number of cancer patients has an escalating economic impact to public health systems (approximately, International dollars- Int$ 60 billion annually in Brazil). Physical activity is widely recognized as one important modifiable risk factor for cancer. Herein, we estimated the economic costs of colon and post-menopausal breast cancers in the Brazilian Unified Health System (SUS) attributable to lack of physical activity. METHODS: Population attributable fractions were calculated using prevalence data from 57,962 adults who answered a physical activity questionnaire in the Brazilian National Health Survey, and relative risks of colon and breast cancer from a meta-analysis. Annual costs (1 Int$ = 2.1 reais) with hospitalization, chemotherapy and radiotherapy were obtained from the Hospital and Ambulatory Information Systems of the Brazilian SUS. Two counterfactual scenarios were considered: theoretical minimum risk exposure level (≥8000 MET-min/week) and physical activity guidelines (≥600 MET-min/week). RESULTS: Annually, the Brazilian SUS expended Int$ 4.5 billion in direct costs related to cancer treatment, of which Int$ 553 million due to colon and breast cancers. Direct costs related to colon and breast cancers attributable to lack of physical activity were Int$ 23.4 million and Int$ 26.9 million, respectively. Achieving at least the physical activity guidelines would save Int$ 10.3 mi (colon, Int$ 6.4 mi; breast, Int$ 3.9 mi). CONCLUSIONS: Lack of physical activity accounts for Int$ 50.3 million annually in direct costs related to colon and post-menopausal breast cancers. Population-wide interventions aiming to promote physical activity are needed to reduce the economic burden of cancer in Brazil.

A espiritualidade/religiosidade como desafio ao cuidado integral: aspectos regulatórios na formação médica brasileira / Spirituality/religiosity as a challenge to comprehensive care: regulatory aspects in Brazilian medical education

Resumo Apesar das evidências apontarem que a abordagem da espiritualidade/religiosidade na prática clínica está relacionada à redução da mortalidade, à melhora da qualidade de vida e da saúde mental, a falta de treinamento é referida pelos médicos como uma barreira para que tal abordagem aconteça. No Brasil, existem marcos legais que ordenam a formação em saúde, ainda pouco estudados. O objetivo deste estudo foi mapear como documentos normativos da formação médica (de graduação e pós-graduação) abordam a dimensão espiritual/religiosa. Trata-se de estudo qualitativo descritivo exploratório do tipo análise documental, sendo considerados documentos: as Diretrizes Curriculares Nacionais (DCN) do curso de Medicina, os Projetos Políticos Pedagógicos (PPPs) de 20 universidades federais selecionadas e as resoluções do Conselho Nacional de Residência Médica em vigor sobre os requisitos mínimos dos Programas de Residência Médica (PRM). A dimensão espiritual/religiosa não foi mencionada nas DCN de medicina, esteve presente em metade dos PPPs analisados e apenas em um programa de residência médica, a Psiquiatria.

Abstract The aim of this study was to assess the quality of oral care provided in Brazilian primary care and identify associated contextual socioeconomic factors. This is a cross-sectional study whose unit of analysis was all the oral care teams that participated in an external assessment for the second cycle of the Access and Quality Improvement Program - Primary Care. Quality was measured in the following dimensions: access, resolution, work process, care coordination and infrastructure. The quality criteria of the external assessment were grouped into these dimensions and weighted using Item Response Theory. The indicator of oral care quality was the result of grouping latent variables. Descriptive analyses were performed by region and association between "Oral Care Quality" and the Municipal Human Development Index (HDI), with 5% significance. Only 25% of the oral care teams were considered good. The infrastructure dimension obtained the best results and care coordination the worst. There was no statistically significant difference between municipalities with high and low HDIs. Quality assessment is vital to ensure the continuous improvement of quality healthcare.

Contemporary Trends of Inpatient Surgical Management of Stone Disease: National Analysis in an Economic Growth Scenario.

PURPOSE: To assess trends in urologic surgical management of upper tract urolithiasis in Brazil over the past 15 years. MATERIALS AND METHODS: The Public Health System of Brazil (SUS) provides health coverage to 47% to 74% of the population. SUS has a longitudinal hospital inpatient database (SIH/SUS). Hospital discharges between January 1,1998 and December 31, 2012 were abstracted from the SIH/SUS. All inpatient hospitalizations for patients of any age with a primary/secondary diagnosis code of N20.x (calculus of kidney or ureter) were abstracted (ICD-9/10). All urolithiasis-related procedure codes were analyzed. The absolute number of procedures/year and the proportion among all techniques were analyzed for Brazil and also separately for the five distinguished regions of the country. Prevalence trends over the studied period were quantified by the estimated annual percent change (EAPC) using the least squares linear regression methodology. Significance was set at P<0.05. RESULTS: The number of surgical interventions for stone disease increased significantly from 10080 to 24713 (+145%; EAPC=1008.1; P<0.001). The most common surgical modalities in 1998 were nephrectomy (n=2918; 29%), ureterolithotomy (n=2361; 23%), and pyelolithotomy (n=1771; 18%). In 2012, ureteroscopy (URS) was the most commonly performed procedure (n=8725; 35%), followed by ureterolithotomy (n=5822; 24%), and nephrectomy (n=3466; 14%). Between 1998 and 2012, percutaneous nephrolithotomy had the highest significant relative increase (+791.8%; EAPC=0.6%; P<0.001), followed by URS (+607%; EAPC=1.78%; P<0.001). Pyelolithotomy showed the most significant decrease (-47.5%; EAPC = -0.91%; P<0.001). All five regions presented a significant positive increase in the EAPC (P<0.001). CONCLUSION: Trends of stone disease surgical management in the public health system of Brazil follow worldwide tendencies toward less invasive treatment modalities.

Fatores associados à não-adesão ao tratamento com anti-hipertensivos em pessoas atendidas em unidades de saúde da família / Risk factors associated with non-adherence to anti-hypertensive medication among patients treated in family health care facilities

In order to estimate the prevalence of treatment non-adherence and associated factors among individuals with systemic arterial hypertension treated at family health care facilities, a cross-sectional study was performed with 595 patients. The dependent variable non-adherence was measured with a Medication Adherence Questionnaire (MAQ). A hierarchical logistic regression model was used to analyze socioeconomic, health care-related, personal, and treatment-related variables. Prevalence of non-adherence was 53 percent. Variables associated with non-adherence were: (1) socioeconomic _ belonging to economic classes C, D, or E; work market participation in unskilled labor; (2) health care _ out-of-pocket payment for medication; more than six months since last physician consultation; and (3) personal and treatment characteristics _ previous interruption of treatment; being on treatment for less than three years; and presence of a common mental disorder. The study of determinants of non-adherence articulated in a hierarchical model suggests that social inequalities are either directly associated with non-adherence or mediated by personal and health services factors.

Para estimar a prevalência e analisar fatores associados à não-adesão ao tratamento de pessoas com hipertensão arterial sistêmica, atendidas em unidades de saúde da família, procedeu-se a estudo transversal com 595 pacientes. A variável dependente não-adesão foi medida com questionário (Questionário de Adesão a Medicamentos - QAM-Q). Foram coletadas variáveis sócio-econômicas, assistenciais, pessoais e do tratamento, analisadas por modelo de regressão logística hierarquizado. A prevalência de não-adesão foi de 53 por cento. As variáveis associadas à não-adesão foram: (1) sócio-econômicas _ pertencer às classes econômicas C/D/E, estar inserido no mercado de trabalho, em ocupações não qualificadas; (2) assistenciais _ precisar comprar os medicamentos e mais que 6 meses desde a última consulta, e; (3) características das pessoas e do tratamento _ interromper previamente o tratamento, estar em tratamento há menos de 3 anos e presença de transtorno mental comum. O estudo dos determinantes da não-adesão articulados em um modelo hierarquizado sugere que as desigualdades sociais se mostram diretamente associadas à não-adesão, ou mediadas por fatores dos serviços e das pessoas.

Avaliação da assistência a pessoas com hipertensão arterial em unidades de estratégia saúde da família / Evaluation of care provided for people with arterial hypertension in family health strategy services

OBJETIVO: analisar a assistência a pessoas com hipertensão arterial sistêmica (HAS) prestada por equipes de Estratégia Saúde da Família (ESF) em Blumenau-SC. MÉTODOS: foram entrevistadas 595 pessoas com HAS moradoras da área de 10 ESF. As variáveis estudadas foram: características demográficas e socioeconômicas, estilo de vida, tratamento, comorbidades, adesão ao tratamento, satisfação com o serviço e níveis pressóricos. Na análise, utilizaram-se os testes de "t de Student" e Qui-quadrado. RESULTADOS: a idade média foi 60,6 anos. Houve predomínio do sexo feminino, cor branca, casadas, com até quatro anos de estudo, sem trabalhar, das classes C e D. A média de escolaridade foi maior em pessoas brancas e das classes A e B (p<0,001). Relataram tabagismo 13,1 por cento e consumo de álcool 23,7 por cento. O tempo médio de uso de medicamentos para HAS foi de 127,9 meses, em média 1,9 medicamentos, e a monoterapia com inibidores da enzima de conversão da angiotensina foi o esquema mais frequente (19,6 por cento). Relataram reações adversas 20,6 por cento, que estavam associadas ao maior número de medicamentos (p<0,02). Mais de 90 por cento se mostraram satisfeitos com os serviços. A prevalência de não adesão ao tratamento medicamentoso foi de 53,1 por cento. Apresentaram PA > 140x90mmHg 69,3 por cento. O descontrole pressórico mostrou-se associado a não adesão, sedentarismo e classes C/D/E. CONCLUSÕES: apesar do acesso a consultas e medicamentos e da satisfação dos usuários, os valores elevados de não adesão e dos níveis pressóricos colocam como desafio a melhoria da qualidade da assistência.

BACKGROUND: to analyse the health care provided for people with arterial hypertension by family health strategy teams in Blumenau, state of Santa Catarina, Brazil. METHODS: overall, 595 people with arterial hypertension who live in the area of 10 family health teams were interviewed. The studied variables were: demographic and socio-economic characteristics, life style, treatment, co-morbidities, adherence to treatment, satisfaction with health service and blood pressure. Descriptive statistics and association tests (Student's t-test, ANOVA, chi-square) were used. RESULTS: the mean age was 60.6 years old. Most are female, white, married, with four or less years of formal education, unemployed, and with low social status. White people and those with high social status had more years of schooling (p<0.001); 13.1% reported smoking and 23.7%, use of alcohol. The mean time of use of hypertension medicines was 127.9 months, on average, 1.9 medicines, and isolated ACE inhibitors were the most used medicines (19.6%). Adverse drug reactions were reported by 20.6%, which were associated with higher number of medicines (p<0.02). More than 90% were satisfied with health services. The prevalence of non-adherence to medicines was 53.1%. Blood pressure > 140x90mmHg was presented by 69.3% and was associated to non-adherence, sedentariness and low social status.CONCLUSIONS: although there is access to care and medicines and despite people's satisfaction with the care provided, high prevalence of non-adherence and uncontrolled blood pressure highlight the need of improving the quality of care.

Assessing screening practices among health care workers at a tertiary-care hospital in Sao Paulo, Brazil.

OBJECTIVE: To ascertain the extent to which screening procedures (with and without evidence of effectiveness) are practiced among health care workers at a tertiary-care hospital in Sao Paulo, Brazil. METHODS: From February 2001 to September 2003, a cross-sectional study involving physicians, nurses and nursing assistants (aged 40 to 69 years) was carried out at a tertiary-care hospital in the city of Sao Paulo, Brazil. Subjects were interviewed using a questionnaire that addresses 17 procedures with grades of recommendation of A, B, C, D or E, in accordance with the 1996 United States Preventive Services Task Force guidelines for routine screening. RESULTS: Of the 333 health care workers included, 228 (68.5%) were female. The mean age was 48.8 (SD 6.6 years). Most subjects had undergone screening for hypertension (blood pressure measurement) and lipid abnormalities (cholesterol testing). Screening for breast and cervical cancer was common among females. Resting electrocardiography, serum glucose testing, urine tests, chest X-rays and serum prostate-specific antigen testing were also quite common. However, only 6 (1.8%) of the subjects had undergone screening for colorectal cancer (fecal occult blood test or sigmoidoscopy). CONCLUSIONS: A sizeable proportion of health care workers underwent screening procedures that are not recommended or for which there was insufficient evidence of a benefit. Conversely, certain recommended procedures were performed on a small proportion of such workers. These results indicate that the Brazilian National Ministry of Health must develop nationwide evidence-based screening recommendations and disseminate such recommendations among health care professionals in Brazil.

[Risk factors associated with non-adherence to anti-hypertensive medication among patients treated in family health care facilities]. / Fatores associados à não-adesão ao tratamento com anti-hipertensivos em pessoas atendidas em unidades de saúde da família.

In order to estimate the prevalence of treatment non-adherence and associated factors among individuals with systemic arterial hypertension treated at family health care facilities, a cross-sectional study was performed with 595 patients. The dependent variable non-adherence was measured with a Medication Adherence Questionnaire (MAQ). A hierarchical logistic regression model was used to analyze socioeconomic, health care-related, personal, and treatment-related variables. Prevalence of non-adherence was 53%. Variables associated with non-adherence were: (1) socioeconomic--belonging to economic classes C, D, or E; work market participation in unskilled labor; (2) health care--out-of-pocket payment for medication; more than six months since last physician consultation; and (3) personal and treatment characteristics--previous interruption of treatment; being on treatment for less than three years; and presence of a common mental disorder. The study of determinants of non-adherence articulated in a hierarchical model suggests that social inequalities are either directly associated with non-adherence or mediated by personal and health services factors.

Assessing screening practices among health care workers at a tertiary-care hospital in Sao Paulo, Brazil

OBJECTIVE: To ascertain the extent to which screening procedures (with and without evidence of effectiveness) are practiced among health care workers at a tertiary-care hospital in Sao Paulo, Brazil. METHODS: From February 2001 to September 2003, a cross-sectional study involving physicians, nurses and nursing assistants (aged 40 to 69 years) was carried out at a tertiary-care hospital in the city of Sao Paulo, Brazil. Subjects were interviewed using a questionnaire that addresses 17 procedures with grades of recommendation of A, B, C, D or E, in accordance with the 1996 United States Preventive Services Task Force guidelines for routine screening. RESULTS: Of the 333 health care workers included, 228 (68.5 percent) were female. The mean age was 48.8 (SD 6.6 years). Most subjects had undergone screening for hypertension (blood pressure measurement) and lipid abnormalities (cholesterol testing). Screening for breast and cervical cancer was common among females. Resting electrocardiography, serum glucose testing, urine tests, chest X-rays and serum prostate-specific antigen testing were also quite common. However, only 6 (1.8 percent) of the subjects had undergone screening for colorectal cancer (fecal occult blood test or sigmoidoscopy). CONCLUSIONS: A sizeable proportion of health care workers underwent screening procedures that are not recommended or for which there was insufficient evidence of a benefit. Conversely, certain recommended procedures were performed on a small proportion of such workers. These results indicate that the Brazilian National Ministry of Health must develop nationwide evidence-based screening recommendations and disseminate such recommendations among health care professionals in Brazil.

Role of 18F-fluorodeoxyglucose positron emission tomography in preoperative assessment of cytologically indeterminate thyroid nodules.

OBJECTIVE: The objective of the study was to determine the diagnostic accuracy of (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) in the preoperative diagnosis of thyroid nodules with indeterminate fine-needle aspiration biopsy results. METHODS: Forty-two consecutive patients with thyroid nodules with indeterminate cytological results participated in this study. Abnormal (18)F-FDG PET uptake was assessed visually and by measuring the maximum standardized uptake value (SUVmax) in thyroid topography. All these results were compared with the final pathological results. RESULTS: The presence of focal uptake correlated with a greater risk of malignancy (P = 0.018). All 11 malignant nodules had focal uptake (sensitivity of 100%). Of the 31 patients with benign nodules, there were 19 with positive uptake (specificity of 38.7%). The pre-PET probability of cancer was 26.2% (11 of 42), and this probability increased to 36.7% after PET for those patients whose exam showed focal uptake (11 of 30). The preoperative use of (18)F-FDG PET would result in a significant reduction (39%, 12 of 31) in the number of thyroidectomies performed in patients with benign lesions. SUVmax could not improve this degree of accuracy. There was no correlation between thyroid nodule size and SUVmax value (P = 0.96). Patients with carcinomas were younger than patients with benign lesions (P = 0.048). There was no other clinical, laboratory, or ultrasonographic variable related to malignancy. CONCLUSIONS: (18)F-FDG PET provides high sensitivity to malignant lesions and may be a potentially useful tool in the evaluation of thyroid nodules with indeterminate cytological findings. For these nodules the number of unnecessary thyroidectomies in a hypothetical algorithm using (18)F-FDG PET would be reduced by 39%.

Agressäo física e classe social / Physical aggression and social class

Considerando-se o aumento da violência e a escassez de informaçöes sobre a relaçäo classe social e vitimizaçäo por agressäo física, realizou-se estudo com o objetivo de investigar esta associaçäo. Foi adotado o estudo de caso-controle. Foram incluídos 191 casos de agressäo física e 222 controles selecionados entre os indivíduos com queixas clínico-cirúrgicas näo violentas, pareados por freqüência aos casos segundo sexo e idade, todos recrutados no período de 1/10/93 a 19/1/95, em pronto-socorro de Sorocaba, SP, Brasil. Foi aplicado questionário para obtençäo de informaçöes sobre classe social, cor, situaçäo conjugal, hábito de fumar, ingestäo de álcool e uso de drogas ilícitas. Ajustando-se os resultados por sexo, idade e os outros fatores estudados encontrou-se um risco de vitimizaçäo por agressäo física significantemente maior para o subproletariado, com "Odds ratio" igual a 3,28 e Intervalo de Confiança de 95 por cento igual a 1,42-7,59. Classe social é um fator importante no fenômeno da vitimizaçäo por agressäo física, devendo o subproletariado receber atençäo especial nas estratégias de intervençäo para o problema