Genomic prediction for meat and carcass traits in Nellore cattle using a Markov blanket algorithm.

This study was carried out to evaluate the advantage of preselecting SNP markers using Markov blanket algorithm regarding the accuracy of genomic prediction for carcass and meat quality traits in Nellore cattle. This study considered 3675, 3680, 3660 and 524 records of rib eye area (REA), back fat thickness (BF), rump fat (RF), and Warner-Bratzler shear force (WBSF), respectively, from the Nellore Brazil Breeding Program. The animals have been genotyped using low-density SNP panel (30 k), and subsequently imputed for arrays with 777 k SNPs. Four Bayesian specifications of genomic regression models, namely Bayes A, Bayes B, Bayes Cπ and Bayesian Ridge Regression methods were compared in terms of prediction accuracy using a five folds cross-validation. Prediction accuracy for REA, BF and RF was all similar using the Bayesian Alphabet models, ranging from 0.75 to 0.95. For WBSF, the predictive ability was higher using Bayes B (0.47) than other methods (0.39 to 0.42). Although the prediction accuracies using Markov blanket of SNP markers were lower than those using all SNPs, for WBSF the relative gain was lower than 13%. With a subset of informative SNPs markers, identified using Markov blanket, probably, is possible to capture a large proportion of the genetic variance for WBSF. The development of low-density and customized arrays using Markov blanket might be cost-effective to perform a genomic selection for this trait, increasing the number of evaluated animals, improving the management decisions based on genomic information and applying genomic selection on a large scale.

All Patient Refined-Diagnosis Related Groups' (APR-DRGs) Severity of Illness and Risk of Mortality as predictors of in-hospital mortality.

The aims of this study were to assess All-Patient Refined Diagnosis-Related Groups' (APR-DRG) Severity of Illness (SOI) and Risk of Mortality (ROM) as predictors of in-hospital mortality, comparing with Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) scores. We performed a retrospective observational study using mainland Portuguese public hospitalizations of adult patients from 2011 to 2016. Model discrimination (C-statistic/ area under the curve) and goodness-of-fit (R-squared) were calculated. Our results comprised 4,176,142 hospitalizations with 5.9% in-hospital deaths. Compared to the CCI and ECI models, the model considering SOI, age and sex showed a statistically significantly higher discrimination in 49.6% (132 out of 266) of APR-DRGs, while in the model with ROM that happened in 33.5% of APR-DRGs. Between these two models, SOI was the best performer for nearly 20% of APR-DRGs. Some particular APR-DRGs have showed good discrimination (e.g. related to burns, viral meningitis or specific transplants). In conclusion, SOI or ROM, combined with age and sex, perform better than more widely used comorbidity indices. Despite ROM being the only score specifically designed for in-hospital mortality prediction, SOI performed better. These findings can be helpful for hospital or organizational models benchmarking or epidemiological analysis.

Economic values of reproductive, growth, feed efficiency and carcass traits in Nellore cattle.

A bioeconomic model was developed to calculate the economic value (ev) of reproductive and growth performance, feed efficiency and carcass traits of a seedstock Nellore herd. Data from a full-cycle cattle operation (1,436 dams) located in the Brazilian Cerrado were assessed. The ev was calculated by the difference in profit before and after one-unit improvement in the trait, with others remaining unchanged. The ev was standardized by the phenotypic standard deviation of each trait. Preweaning average daily gain (ADG) was the most economically important trait evaluated (R$ 58.04/animal/year), followed by age at first calving (R$ 44.35), postweaning ADG (R$ 31.43), weight at 450 days (R$ 25.36), accumulated productivity (R$ 21.43), ribeye area (R$ 21.35), calving interval (R$ 19.97), feed efficiency (R$ 15.24), carcass dressing per cent (R$ 8.27), weight at 120 days (R$ 6.22), weight at 365 days (R$ 6.06), weight at weaning (210 days, R$ 5.82), stayability (R$ 5.70) and the probability of early calving (R$ 0.32). The effects of all traits on profits are evidence that their selection may result in the economic and genetic progress of the herd if there is genetic variability.

Problems and Barriers during the Process of Clinical Coding: a Focus Group Study of Coders' Perceptions.

Coded data are the basis of information systems in all countries that rely on Diagnosis Related Groups in order to reimburse/finance hospitals, including both administrative and clinical data. To identify the problems and barriers that affect the quality of the coded data is paramount to improve data quality as well as to enhance its usability and outcomes. This study aims to explore problems and possible solutions associated with the clinical coding process. Problems were identified according to the perspective of ten medical coders, as the result of four focus groups sessions. This convenience sample was sourced from four public hospitals in Portugal. Questions relating to problems with the coding process were developed from the literature and authors' expertise. Focus groups sessions were taped, transcribed and analyzed to elicit themes. Variability in the documents used for coding, illegibility of hand writing when coding on paper, increase of errors due to an extra actor in the coding process when transcribed from paper, difficulties in the diagnoses' coding, coding delay and unavailability of resources and tools designed to help coders, were some of the problems identified. Some problems were identified and solutions such as the standardization of the documents used for coding an episode, the adoption of the electronic coding, the development of tools to help coding and audits, and the recognition of the importance of coding by the management were described as relevant factors for the improvement of the quality of data.

Health records as the basis of clinical coding: Is the quality adequate? A qualitative study of medical coders' perceptions.

BACKGROUND: Health records are the basis of clinical coding. In Portugal, relevant diagnoses and procedures are abstracted and categorised using an internationally accepted classification system and the resulting codes, together with the administrative data, are then grouped into diagnosis-related groups (DRGs). Hospital reimbursement is partially calculated from the DRGs. Moreover, the administrative database generated with these data is widely used in research and epidemiology, among other purposes. OBJECTIVE: To explore the perceptions of medical coders (medical doctors) regarding possible problems with health records that may affect the quality of coded data. METHOD: A qualitative design using four focus groups sessions with 10 medical coders was undertaken between October and November 2017. The convenience sample was obtained from four public hospitals in Portugal. Questions related to problems with the coding process were developed from the literature and authors' expertise. The focus groups sessions were taped, transcribed and analysed to elicit themes. RESULTS: There are several problems, identified by the focus groups, in health records that influence the coded data: the lack of or unclear documented information; the variability in diagnosis description; "copy & paste"; and the lack of solutions to solve these problems. CONCLUSION AND IMPLICATIONS: The use of standards in health records, audits and physician awareness could increase the quality of health records, contributing to improvements in the quality of coded data, and in the fulfilment of its purposes (e.g. more accurate payments and more reliable research).

O restabelecimento do pacto federativo na judicialização da saúde: a paralisia da União e o julgamento do Recurso Extraordinário nº 855178 pelo Supremo Tribunal Federal / The reestablishment of the federative pact in the judicialization of health: Federal government paralysis and the judgment of Extraordinary Appeal nº 855.178 by the Supreme Court

Objetivo: expor soluções que tornem possível e efetivo o ressarcimento dos entes estaduais por parte da União nas demandas envolvendo o direito à saúde, de modo a reequilibrar o pacto federativo. Metodologia: pesquisa de caráter bibliográfico e documental, desenvolvida com base em material já elaborado, constituído de livros, artigos, documentos e jurisprudência dos tribunais. Resultados: o artigo apresenta ferramentas jurídicas que podem ser utilizadas para forçar a atuação da União Federal e reequilibrar o pacto federativo nas demandas envolvendo o direito à saúde, tendo em vista a inércia da União em realizar o ressarcimento dos entes públicos estaduais. Realça a reconfiguração do protagonismo da União quanto ao financiamento de tratamentos envolvendo medicamentos de alto custo e oncológicos não incorporados ao Sistema Único de Saúde (SUS). Conclusão: após o julgamento do Recurso Extraordinário nº 855.178, foram fixados parâmetros que devem ser obrigatoriamente aplicados a fim de compatibilizar o direito à saúde dos jurisdicionados e a repartição de competências no SUS, de modo a restabelecer o pacto federativo na judicialização da saúde. (AU).

Objective: To present solutions that make possible the reimbursement of state entities by the Federal government in demands involving the right to health, in order to rebalance the federative pact. Methodology: analysis of the judgment of the extraordinary appeal nº 855.178 by the Supreme Court, which established a new thesis on the joint and several liability of federated entities for the duty to provide health care; bibliographic and documentary research, developed based on material already prepared, consisting of books, articles, documents and jurisprudence of the courts. Results: the article presents legal tools that can be used to force the Federal government action and to rebalance the federal pact in the demands involving the right to health, considering the inertia of the Federal government in making the reimbursement of state public entities. It highlights the reconfiguration of the Federal government role in financing treatments involving non-SUS, high cost and cancer drugs. Conclusion: after the judgment of the RE 855,178, parameters were set that must be enforced in order to make the right to health of the citizens and the division of competences in the SUS compatible, in order to reestablish the federative pact in the judicialization of health. (AU).

Objetivo: presentar soluciones que hagan posible el reembolso de entidades estatales por parte de la Unión en demandas relacionadas con el derecho a la salud, para reequilibrar el pacto federativo. Metodología: análisis de la sentencia del RE nº 855.178 del Supremo Tribunal Federal, que estableció una nueva tesis sobre la responsabilidad solidaria de las entidades federadas por el deber de brindar atención médica; Investigación bibliográfica y documental, desarrollada en base a material ya preparado, consistente en libros, artículos, documentos y jurisprudencia de los tribunales. Resultados: el artículo presenta herramientas legales que pueden usarse para forzar la acción de la Unión Federal y reequilibrar el pacto federal en las demandas que involucran el derecho a la salud, considerando la inercia de la Unión al hacer el reembolso de las entidades públicas estatales. Destaca la reconfiguración del papel de la Unión en el financiamiento de tratamientos que involucran medicamentos no incorporados en SUS, de alto costo y contra el cáncer. Conclusión: después de la sentencia del RE nº 855,178, se establecieron parámetros que deben hacerse cumplir para que el derecho a la salud de los ciudadanos y la división de competencias en el SUS sean compatibles, a fin de restablecer el pacto federativo en la judicialización de la salud. (AU).

O financiamento pelos Estados de política pública de saúde de atribuição da União: a afronta às disposições da Lei de Responsabilidade Fiscal e à regra de ouro do Direito Financeiro / Federal health policy financing by subnational entities: the affront to the provisions of the Fiscal Responsibility Law and to the golden rule of Financial Law

Objetivo: analisar decisões em ações judiciais, nas quais há determinação para que os entes demandados realizem o reembolso financeiro na via administrativa em razão do cumprimento de prestações obrigacionais relacionadas ao direito à saúde. Métodos: revisão bibliográfica e legislativa e aplicação do método de análise dedutivo, a partir da comparação entre os valores pagos pelos entes estatais e a ausência de reembolso administrativo da União. Resultados: inocorrência do reembolso administrativo por ausência de normas regulamentares específicas e omissão da União. Conclusões: a determinação judicial de reembolso administrativo entre os réus, em ações relacionadas ao direito à saúde, afronta as disposições legais que proíbem a realização de operações de crédito entre entes federados, surgindo a necessidade de que o reembolso pelo cumprimento da decisão do Poder Judiciário ocorra no curso da ação judicial. (AU).

Objective: to analyze decisions in lawsuits, in which there is determination for the defendants to make the financial reimbursement on the administrative route due to the fulfillment of mandatory benefits related to the right to health. Methods: bibliographic and legislative review and application of the deductive analysis method, from the comparison between the amounts paid by the state entities and the absence of administrative reimbursement of the Union. Results: inocurrence of administrative reimbursement for the absence of specific regulatory norms and omission of the Union. Conclusions: the judicial determination of administrative reimbursement between defendants, in actions related to the right to health, violates the legal provisions that prohibit the execution of credit operations between federated entities, resulting in the need for reimbursement for compliance with the decision of the Judiciary occurs in the course of the lawsuit. (AU).

Objetivo: analizar las decisiones en los juicios, en los cuales existe una determinación para los acusados de realizar el reembolso financiero en la ruta administrativa debido al cumplimiento de los beneficios obligatorios relacionados con el derecho a la salud. Métodos: revisión y aplicación bibliográfica y legislativa del método de análisis deductivo, a partir de la comparación entre los montos pagados por las entidades estatales y la ausencia de reembolso administrativo de la Unión. Resultados: incurrencia de reembolso administrativo por la ausencia de normas regulatorias específicas y la omisión de la Unión. Conclusiones: la determinación judicial del reembolso administrativo entre los acusados, en acciones relacionadas con el derecho a la salud, viola las disposiciones legales que prohíben la ejecución de operaciones de crédito entre entidades federadas, lo que resulta en la necesidad de reembolso por el cumplimiento de la decisión del poder judicial ocurre en el curso de la demanda. (AU).

Quality of coding within clinical datasets: A case-study using burn-related hospitalizations.

The quality of clinical data held in administrative databases is crucial for appropriate funding of health care services. As Diagnosis-Related Groups (DRGs) continue to play an important role in hospital payment mechanisms, proper coding of diagnoses and procedures is of most concern. This study used an administrative, nationwide Portuguese inpatient database to characterize and assess coding patterns in burn-related hospitalization data, with a special focus on identifying suspected miscoding practices that could be affecting APR-DRG (All-Patient Refined Diagnosis-Related Groups) classification. Using coded clinical data of 4,182 burn-related admissions occurred between 2011 and 2015, we compared APR-DRG and Severity of Illness (SOI) frequencies between hospitals with a burn unit in Portugal. The frequencies of individual diagnosis and procedure codes among episodes grouped within the same APR-DRG were also compared. Hospitals with a burn unit in Portugal differed significantly in the frequencies of APR-DRGs 842 and 844. Proper coding of extensive third-degree burns might be related with the observed discrepant frequencies of APR-DRGs across the evaluated hospitals. Facilities also differed significantly concerning the proportions of SOI levels in certain APR-DRGs. Significant differences in reporting certain comorbidities and common hospital procedures, especially non-operating room procedures, might have influenced the observed discrepancies in SOI levels. Moreover, there seems to be a lack of standard in coding debridement procedures among the evaluated hospitals. Overall, we found some suspected coding patterns that could potentially be associated with miscoding practices impacting APR-DRG classification. Those findings could not only be relevant for planning future audit processes and improving medical coding practices, but also for discussing quality and desirable features of burn-related clinical data, keeping in mind their use for other purposes beyond DRG grouping, namely clinical and health care services research, as well as health care management.

A simple, cost-effective method for generating murine colonic 3D enteroids and 2D monolayers for studies of primary epithelial cell function.

Cancer cell lines have been the mainstay of intestinal epithelial experimentation for decades, due primarily to their immortality and ease of culture. However, because of the inherent biological abnormalities of cancer cell lines, many cellular biologists are currently transitioning away from these models and toward more representative primary cells. This has been particularly challenging, but recent advances in the generation of intestinal organoids have brought the routine use of primary cells within reach of most epithelial biologists. Nevertheless, even with the proliferation of publications that use primary intestinal epithelial cells, there is still a considerable amount of trial and error required for laboratories to establish a consistent and reliable method to culture three-dimensional (3D) intestinal organoids and primary epithelial monolayers. We aim to minimize the time other laboratories spend troubleshooting the technique and present a standard method for culturing primary epithelial cells. Therefore, we have described our optimized, high-yield, cost-effective protocol to grow 3D murine colonoids for more than 20 passages and our detailed methods to culture these cells as confluent monolayers for at least 14 days, enabling a wide variety of potential future experiments. By supporting and expanding on the current literature of primary epithelial culture optimization and detailed use in experiments, we hope to help enable the widespread adoption of these innovative methods and allow consistency of results obtained across laboratories and institutions.NEW & NOTEWORTHY Primary intestinal epithelial monolayers are notoriously difficult to maintain culture, even with the recent advances in the field. We describe, in detail, the protocols required to maintain three-dimensional cultures of murine colonoids and passage these primary epithelial cells to confluent monolayers in a standardized, high-yield and cost-effective manner.

Trends in hospital admissions for obstructive lung disease from 2000 to 2010 in Portugal.

The burden of hospitalisations for obstructive lung diseases (OLD) has not been sufficiently studied. We aimed to characterise the hospitalisations for OLD from 2000 to 2010 in all Portuguese public hospitals. We analysed hospital discharges with a diagnosis of OLD regarding the patients' gender, age, residence and comorbidities. Of the 120 399 hospital admissions with a principal diagnosis of OLD, COPD (ICD-9-CM 491.x, 492.x, 496) was responsible for 81%. The change in patients discharged with OLD as a principal diagnosis was only 1% from 2000 to 2010 and did not change for COPD. Hospital admissions and deaths for COPD and other OLD increased with age and were more common in men than women. In-hospital mortality for COPD decreased 34.1% from 2000 to 2010, while the median length of stay was fairly constant at 8 days. Respiratory failure, insufficiency and/or arrest, and pneumonia, are the principal diagnoses often associated with COPD. When both pneumonia and COPD were diagnosed there was an increasing trend to classify pneumonia as the principal diagnosis (64.4%-72.9%), a sign that may lead to underestimation of COPD hospitalisations. In summary, a considerable decrease in in-hospital COPD mortality was observed while hospital admissions and the length of stay did not change substantially. These results suggest that better healthcare or other factors may be counteracting the expected increase of the burden of COPD.

HIV disease burden, cost, and length of stay in Portuguese hospitals from 2000 to 2010: a cross-sectional study.

BACKGROUND: The number of HIV-related hospitalizations has decreased worldwide in recent years owing to the availability of highly active antiretroviral therapy. However, the change in HIV-related hospitalizations in Portugal has not been studied. Using comprehensive hospital discharge data from mainland Portuguese hospitals, we examined trends in HIV-related inpatient admissions, length of stay (LOS), Elixhauser comorbidity measures, in-hospital mortality, and mean cost from 2000 to 2010. METHODS: The hospital administrative data from inpatient admissions and discharges at 75 public acute care hospitals in the Portuguese National Health Service from 2000 to 2010 were included. HIV-related admissions were identified using the International Classification of Diseases, 9(th) Revision, Clinical Modification diagnosis codes 042.x-044.x. The effect of Elixhauser comorbidity measures on extending the LOS was assessed by comparing admissions in HIV patients with and without comorbidities using the Mann-Whitney U test. Multivariate logistic regression was performed to estimate the odds of having a decreased discharge. RESULTS: A total of 57,027 hospital admissions were analyzed; 73% of patients were male, and the mean age was 39 years. The median LOS was 11 days, and the in-hospital mortality was 14%. The mean cost per hospitalization was 5,148.7€. A total of 83% of admissions were through the emergency room. During the period, inpatient HIV admissions decreased by 22%, LOS decreased by 9%, and in-hospital mortality dropped by 12%. Elixhauser comorbidities increased the median LOS in nearly all admissions. CONCLUSIONS: Despite small regional variations, a strong, consistent decrease was observed in the hospital admission rate, mean cost, length of stay, and mortality rate for HIV-related admissions in Portugal during 2000-2010.

[Assessment of competencies of community health workers for epidemiological data collection]. / Avaliação de competências de Agentes Comunitários de Saúde para coleta de dados epidemiológicos.

The scope of this study was to assess competencies in terms of reading, comprehension and problem-solving using educational material created for epidemiological research on people with disabilities. A form with twenty multiple-choice questions was prepared and distributed to a sample of 348 community health workers (CHWs) in the State of Paraíba. The socioeconomic profile revealed that, within the sample, most of these CHWs are female, between 30-49 years of age, married or in a stable relationship, with two children and have graduated from high school. Over 98% of CHWs are government employees and more than half have been working for more than eight years in the same community, predominantly in the urban area. The score for overall performance evaluation ranged from 33 to 60 points, with the mean score of 53.44 ± 4.88 points. This means that the CHWs were able to resolve over 65% of the questions properly. The overall performance was positively correlated with education and negatively with age, having children and the time taken to complete high school education. The overall results indicate the increasing professionalization and education of the CHWs and their potential role as collaborators in basic scientific research to make generalizations about public health.

Avaliação de competências de Agentes Comunitários de Saúde para coleta de dados epidemiológicos / Assessment of competencies of community health workers for epidemiological data collection

Este trabalho objetivou avaliar as competências de leitura, interpretação de texto e resolução de problemas de um material didático criado para pesquisa epidemiológica sobre pessoas com deficiências. Uma avaliação contendo vinte questões de múltipla escolha foi desenvolvida e aplicada em uma amostra de 348 agentes comunitários de saúde no estado da Paraíba. A caracterização socioeconômica da amostra mostrou que a maior parte desses profissionais é constituída por mulheres, de 30 a 49 anos, casadas ou que mantêm união estável, com dois filhos e ensino médio completo. Mais de 98% dos ACS são concursados e atuam há mais de oito anos nesta profissão e predominantemente na zona urbana. A pontuação referente ao desempenho global na avaliação variou de 33 até 60 pontos, sendo obtida a média de 53,44 ± 4,88 pontos. Isto significa que os agentes foram capazes de resolver adequadamente mais de 65% das questões. O desempenho global mostrou correlação positiva com a escolaridade e negativa com a idade, ter filhos e o tempo de conclusão do ensino formal. O conjunto dos resultados aponta a crescente profissionalização e escolarização dos ACS, e seu potencial papel como colaborador em pesquisas científicas fundamentais para estabelecimento de generalizações sobre a saúde das populações.

The scope of this study was to assess competencies in terms of reading, comprehension and problem-solving using educational material created for epidemiological research on people with disabilities. A form with twenty multiple-choice questions was prepared and distributed to a sample of 348 community health workers (CHWs) in the State of Paraíba. The socioeconomic profile revealed that, within the sample, most of these CHWs are female, between 30-49 years of age, married or in a stable relationship, with two children and have graduated from high school. Over 98% of CHWs are government employees and more than half have been working for more than eight years in the same community, predominantly in the urban area. The score for overall performance evaluation ranged from 33 to 60 points, with the mean score of 53.44 ± 4.88 points. This means that the CHWs were able to resolve over 65% of the questions properly. The overall performance was positively correlated with education and negatively with age, having children and the time taken to complete high school education. The overall results indicate the increasing professionalization and education of the CHWs and their potential role as collaborators in basic scientific research to make generalizations about public health.

Multivariate approach for young bull selection from a performance test using multiple traits of economic importance.

This study used multivariate statistics to identify clusters of animals with similar expected progeny difference (EPD) and also identify leading traits that discriminate between bulls. Various linear selection indices based on specific selection criteria were proposed. Records were collected from 880 young Nelore bulls submitted to performance testing in central Brazil between 2001 and 2012. Pre-weaning average daily gain and weights at 210 days with direct and maternal effects were used in the analysis, in addition to post-weaning weight, scrotal circumference at 365 and 450 days, carcass finish and rib eye area. EPDs were classified into three groups, and the EPD means of two of these groups stood out and were considered important based on principal component analysis that associated higher values of direct EPD of weights, average daily weight gain and scrotal circumference. The EPDs for weight at 210, 365 and 450 days, pre- and post-weaning daily gain and scrotal circumference at 365 and 450 days were major causes of variation. Each linear selection index proposed (SI1, SI2, SI3, SI4 and SI5) defined a specific approach meaning that a different selection index should be used depending on breeding goals and selection criteria.

Spatialization of climate, physical and socioeconomic factors that affect the dairy goat production in Brazil and their impact on animal breeding decisions / Espacialização de fatores climáticos, físicos e socioeconômicos que afetam a produção de caprinos leiteiros no Brasil e seu impacto sobre as decisões em melhoramento animal

Brazil has high climate, soil and environmental diversity, as well as distinct socioeconomic and political realities, what results in differences among the political administrative regions of the country. The objective of this study was to determine spatial distribution of the physical, climatic and socioeconomic aspects that best characterize the production of dairy goats in Brazil. Production indices of milk per goat, goat production, milk production, as well as temperature range, mean temperature, precipitation, normalized difference vegetation index, relative humidity, altitude, agricultural farms; farms with native pasture, farms with good quality pasture, farms with water resources, farms that receive technical guidance, family farming properties, non-familiar farms and the human development index were evaluated. The multivariate analyses were carried out to spatialize climatic, physical and socioeconomic variables and so differenciate the Brazilian States and Regions. The highest yields of milk and goat production were observed in the Northeast. The Southeast Region had the second highest production of milk, followed by the South, Midwest and North. Multivariate analysis revealed distinctions between clusters of political-administrative regions of Brazil. The climatic variables were most important to discriminate between regions of Brazil. Therefore, it is necessary to implement animal breeding programs to meet the needs of each region.

O Brasil possui diversidade edafoclimática e realidades socioeconômicas e políticas distintas. Isto contribui para diferenciar as regiões político administrativas do país. Objetivou-se espacializar os fatores físicos, climáticos e socioeconômicos que melhor discriminam a produção de caprinos leiteiros no Brasil. Foram analisados índice de produção de leite por cabra; índice de produção de caprinos; índice de produção de leite, amplitude da temperatura; temperatura média; precipitação; índice normalizado de diferença vegetativa; umidade relativa do ar; altitude; estabelecimentos agropecuários; estabelecimentos com pastagem nativa; estabelecimentos com pastagens de boa qualidade; estabelecimentos com recursos hídricos; estabelecimentos que recebem orientação técnica; estabelecimentos de agricultura familiar; estabelecimentos de agricultura não familiar e índice de desenvolvimento humano. Foram realizadas análises multivariadas para espacializar as variáveis climáticas, físicas e socioeconômicas e, assim, discriminar os Estados e Regiões brasileiras. As maiores produções de caprinos e de leite foram observadas na região Nordeste. A região Sudeste apresentou segunda maior produção de leite, seguido pelo Sul, Centro-Oeste e Norte. As médias para produtividade mostraram que as regiões Centro-Oeste e Sudeste apresentaram animais mais especializados a produção de leite. As análises multivariadas evidenciaram distinções entre clusters das regiões político-administrativas do Brasil. As variáveis climáticas foram as mais importantes para discriminar entre as regiões brasileiras. A heterogeneidade dos componentes climáticos, físicos e socioeconômicos evidenciou peculiaridades em cada região. Portanto, é preciso implementar programas de melhoramento genético animal que atendam as necessidades de cada região.

Factors influencing hospital high length of stay outliers.

BACKGROUND: The study of length of stay (LOS) outliers is important for the management and financing of hospitals. Our aim was to study variables associated with high LOS outliers and their evolution over time. METHODS: We used hospital administrative data from inpatient episodes in public acute care hospitals in the Portuguese National Health Service (NHS), with discharges between years 2000 and 2009, together with some hospital characteristics. The dependent variable, LOS outliers, was calculated for each diagnosis related group (DRG) using a trim point defined for each year by the geometric mean plus two standard deviations. Hospitals were classified on the basis of administrative, economic and teaching characteristics. We also studied the influence of comorbidities and readmissions. Logistic regression models, including a multivariable logistic regression, were used in the analysis. All the logistic regressions were fitted using generalized estimating equations (GEE). RESULTS: In near nine million inpatient episodes analysed we found a proportion of 3.9% high LOS outliers, accounting for 19.2% of total inpatient days. The number of hospital patient discharges increased between years 2000 and 2005 and slightly decreased after that. The proportion of outliers ranged between the lowest value of 3.6% (in years 2001 and 2002) and the highest value of 4.3% in 2009. Teaching hospitals with over 1,000 beds have significantly more outliers than other hospitals, even after adjustment to readmissions and several patient characteristics. CONCLUSIONS: In the last years both average LOS and high LOS outliers are increasing in Portuguese NHS hospitals. As high LOS outliers represent an important proportion in the total inpatient days, this should be seen as an important alert for the management of hospitals and for national health policies. As expected, age, type of admission, and hospital type were significantly associated with high LOS outliers. The proportion of high outliers does not seem to be related to their financial coverage; they should be studied in order to highlight areas for further investigation. The increasing complexity of both hospitals and patients may be the single most important determinant of high LOS outliers and must therefore be taken into account by health managers when considering hospital costs.

Negociação permanente: uma estratégia de gestão possível nas instituições de saúde? / Permanent negotiation: a feasible management strategy in health institutions?

Um dos grandes desafios da administração, tanto pública quanto privada, consiste em gerenciar os conflitos nas organizações, em paralelo ao atendimento adequado das demandas da sociedade e, mais especificamente, dos usuários e consumidores de produtos e serviços. Nesse cenário, a prática da negociação coletiva conquistou um espaço privilegiado por meio das mesas de negociação permanente. Partindo desse pressuposto este trabalho teve como objetivo compreender a dinâmica de funcionamento da Mesa de negociação na secretaria de Saúde do Estado do Rio Grande do Norte/RN. A análise das Atas das reuniões da Mesa permitiu identificar os resultados aqui apresentados, dentre eles a construção de um espaço com vistas à democratização das relações de trabalho.

One o the greatest challenges in both public and private administration in managing organizational conflict while at the same time adequately meeting the demands of society, particularly those of the consumers of goods and services. Collective negotiation has therefore gained ground by means of permanent negotiation tables. This study aims to understand the dynamic and functioning of the negotiating table in the Rio Grande do Norte (RN) State-Health Department. Analysis of the minutes from negotiation table meeting identified the results presented here. These include the construction of a space to foster democratized work relations.

Redes como perspectiva de análise e como estrutura de governança: uma análise das diferentes contribuições / Networks as an analysis perspective and as a governance structure: an analysis of different contributions

Este artigo discute as abordagens de redes nas suas diferentes dimensões, mostrando como elas vêm sendo desenvolvidas, suas distinções e inter-relações. As redes como estrutura de governança e como perspectiva de análise não devem ser excludentes, mas sim dimensões que precisam ser utilizadas de forma integrada. Serão abordadas ainda suas contribuições para análise de fenômenos sociais, suas diferentes formas, limitações e perspectivas teóricas utilizadas para explicar sua formação.