Racial disparities in breast cancer survival after treatment initiation in Brazil: a nationwide cohort study.

BACKGROUND: Breast cancer is a public health priority in Brazil and ensuring equity in health care is one of the cancer control plan goals. Our aim was to present the first assessment on the influence of race or skin colour on breast cancer survival at the national level. METHODS: In this nationwide cohort study, data on women who initiated treatment for breast cancer in the public health-care system (Sistema Unico de Saúde), Brazil, were assembled through record linkage of administrative and mortality information systems. The administrative information systems were the Outpatient Information System (data from high complexity procedure authorisations) and the Hospital Information System (data from hospitalisation authorisations). We included women aged 19 years or older who started treatment between Jan 1, 2008, and Nov 30, 2010; self-identified as having White, Black, or Brown race or skin colour; had tumour stage I-IV; and were treated with chemotherapy or radiotherapy, or both. Patients were followed up until Dec 31, 2015. Patients with only hormone therapy records or who underwent only surgery were excluded. The Kaplan-Meier method was used to estimate crude overall survival for race or skin colour by time since treatment initiation, and Cox regression to estimate all-cause mortality hazard ratios (HRs) before and after adjustment for other covariates. FINDINGS: We identified 59 811 women treated for stage I-IV breast cancer. 37 318 (62·4%) women identified themselves as White, 18 779 (31·4%) as Brown, and 3714 (6·2%) as Black. 5-year overall survival probability was higher for White women (74% [95% CI 73-74]) than Black women (64% [62-65]; p<0·0001). In adjusted regression models stratified by the absence of hormone therapy, Black women had a 24% (HR 1·24 [95% CI 1·16-1·34]; p<0·0001) higher risk of all-cause death than White women, and in the presence of hormone therapy Black women had a 25% (1·25 [1·14-1·38]; p<0·0001) higher risk of all-cause death than White women. INTERPRETATION: Black skin colour was identified as a statistically significant risk marker for lower 5-year survival probability and higher risk of all-cause death among women treated for breast cancer by the Sistema Unico de Saúde. Actions to understand and mitigate this unfair difference in health results are urgently needed. FUNDING: Conselho Nacional de Desenvolvimento Científico e Tecnológico and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior and Pró-Reitoria de Pesquisa da Universidade Federal de Minas Gerais.

Early and Frequent Psychiatric Readmissions in a Brazilian Cohort of Hospitalized Patients Between 2001 and 2013.

OBJECTIVE: To characterize the profile of patients who were readmitted for mental and behavioral disorders, in the Brazilian Unified Health System, from 2001 to 2014, and the factors associated with early and frequent readmission. METHOD: A retrospective, non-concurrent cohort study of patients admitted with a primary diagnosis of mental or behavioral disorders, from 2001 to 2014. This study selected demographic variables and clinical variables, as well as variables related to the characteristics of the hospitals. Poisson Regression methods with a robust variance estimator were used to estimate the incidence rate ratio (IRR) for each of the outcomes. RESULTS: Early readmission occurred for 6.8% of the patients and frequent readmission for 8.3%. Characteristics such as being male, younger, with a diagnosis of a bipolar disorder, and admitted to a specialized hospital show a higher IRR for early readmission. The occurrence of early readmission was the most heavily associated characteristic with an increased rate of early readmission, and the magnitude of this increase depends on the patient's age. CONCLUSION: Early and frequent readmissions are linked to patients' demographics, clinical information and health system's organization. Early readmission should be a priority in treatment planning to prevent frequent readmissions due to its strong association.

[Beneficiaries of private health plans that used the public outpatient hemodialysis network in Brazil between 2012 and 2019]. / Beneficiários de planos privados de saúde que utilizaram a rede pública de hemodiálise ambulatorial no Brasil entre 2012 e 2019.

Reimbursement to Brazilian Unified National Health System (SUS) is the most visible interface of the public-private relationship and its analysis can expand our understanding of the use of SUS by the supplementary sector. The study aims to characterize the beneficiaries of private health plans who underwent hemodialysis in the SUS, from 2012 to 2019, in relation to: gender, age group, region of residence, characteristics of the private health plans and the operators and of the care provided to them. The characteristics of the private health plans and the modality of the operators of the beneficiaries where then compared with data of the other beneficiaries in Brazil. An individual-centered database was constructed based on data from the Brazilian National Supplementary Health Agency (ANS); information on beneficiaries in Brazil was consulted in Brazilian Health Informatics Department (DATASUS). Frequency distributions were used to summarize the data, standardization by age and sex for characteristics of the private health plans and modality of the operators and ratio to compare frequencies. A total of 31,941 beneficiaries underwent hemodialysis in the SUS, 11,147 (34.9%) outside their municipality of residence, and 6,423 (20.11%) used the SUS for 25 months or more. When compared with other beneficiaries in Brazil, those who underwent hemodialysis in the SUS were more frequently linked to old private health plans (ratio, r = 2.41), collective by adherence (r = 1.76), individual/family (r = 1.36), outpatient (r = 4.66), municipal (r = 3.88), and/or philanthropic (r = 7.32). Private health plans with restrictive characteristics may have hindered the access of beneficiaries who performed hemodialysis in SUS to the networks of their operators and have represented one more among the factors that may have influenced the use of SUS by those beneficiaries, even with coverage provided for in their contracts.

O ressarcimento ao Sistema Único de Saúde (SUS) é a interface mais visível da relação entre saúde pública e privada, e sua análise pode ampliar o conhecimento sobre o uso do SUS pelo setor suplementar. O presente estudo objetivou caracterizar os beneficiários de planos privados de saúde que realizaram hemodiálise no SUS entre 2012 e 2019 em relação a: sexo, faixa etária, região de residência, características dos planos privados de saúde e das operadoras e a assistência prestada a eles. Visou também comparar características dos planos privados de saúde e modalidade das operadoras daqueles beneficiários com dados dos demais beneficiários do Brasil. Construiu-se uma base centrada no indivíduo a partir de dados da Agência Nacional de Saúde Suplementar (ANS); informações sobre beneficiários do Brasil foram consultadas no Departamento de Informática do SUS (DATASUS). Utilizou-se distribuições de frequências para resumir os dados, padronização por idade e sexo para características dos planos privados de saúde e modalidade das operadoras, e razão para comparar frequências. Um total de 31.941 beneficiários realizou hemodiálise no SUS, 11.147 (34,9%) destes fora de seu município de residência, e 6.423 (20,11%) utilizaram o SUS por 25 meses ou mais. Comparados aos demais beneficiários do Brasil, aqueles que realizaram hemodiálise no SUS estavam vinculados mais frequentemente a planos privados de saúde antigos (razão, r = 2,41), coletivos por adesão (r = 1,76), individuais/familiares (r = 1,36), ambulatoriais (r = 4,66), municipais (r = 3,88) e/ou a filantropias (r = 7,32). Planos privados de saúde com características restritivas podem ter dificultado o acesso dos beneficiários que realizaram hemodiálise no SUS às redes de suas operadoras, e representado mais um fator que pode ter influenciado o uso do SUS por aqueles beneficiários, mesmo com a cobertura prevista em seus contratos.

El resarcimiento al Sistema Único de Salud (SUS) es la interfaz más visible de la relación público-privada y su análisis puede ampliar el conocimiento sobre el uso del SUS por el sector suplementario. El estudio tuvo como objetivo caracterizar a los beneficiarios de planes privados de salud que realizaron hemodiálisis en el SUS, entre 2012 y 2019, con relación a: género, rango de edad, región de residencia, características de los planes privados de salud y de los operadores y a la asistencia prestada a ellos; y comparar características de los planes privados de salud y modalidad de los operadores de aquellos beneficiarios con datos de los demás beneficiarios de Brasil. Se construyó una base centrada en el individuo a partir de datos de la Agencia Nacional de Salud Suplementaria (ANS); las informaciones sobre los beneficiarios en Brasil fueron consultadas en el Departamento de Informática del SUS (DATASUS). Se utilizaron distribuciones de frecuencia para resumir los datos, la estandarización por edad y género para las características de los planes privados de salud y la modalidad de los operadores y la relación para comparar frecuencias. Un total de 31.941 beneficiarios se sometieron a hemodiálisis en el SUS, 11.147 (34,9 %) fuera de su municipio de residencia y 6.423 (20,11 %) utilizaron el SUS por 25 meses o más. Comparados a los demás beneficiarios de Brasil, los beneficiarios que se sometieron a hemodiálisis en el SUS estaban vinculados más frecuentemente a planes privados de salud antiguos (razón, r = 2,41), colectivos por adhesión (r = 1,76), individuales/familiares (r = 1,36), ambulatorios (r = 4,66), municipales (r = 3,88) y/o a filantropías (r = 7,32). Planes privados de salud con características restrictivas pueden haber dificultado el acceso de los beneficiarios que realizaron hemodiálisis en el SUS a las redes de sus operadores y pueden haber representado un factor más entre los que pueden haber influido en el uso del SUS por aquellos beneficiarios, incluso con cobertura prevista en sus contratos.

Beneficiários de planos privados de saúde que utilizaram a rede pública de hemodiálise ambulatorial no Brasil entre 2012 e 2019 / Beneficiaries of private health plans that used the public outpatient hemodialysis network in Brazil between 2012 and 2019 / Beneficiarios de planes privados de salud que utilizaron la red pública de hemodiálisis ambulatoria en Brasil entre 2012 y 2019

O ressarcimento ao Sistema Único de Saúde (SUS) é a interface mais visível da relação entre saúde pública e privada, e sua análise pode ampliar o conhecimento sobre o uso do SUS pelo setor suplementar. O presente estudo objetivou caracterizar os beneficiários de planos privados de saúde que realizaram hemodiálise no SUS entre 2012 e 2019 em relação a: sexo, faixa etária, região de residência, características dos planos privados de saúde e das operadoras e a assistência prestada a eles. Visou também comparar características dos planos privados de saúde e modalidade das operadoras daqueles beneficiários com dados dos demais beneficiários do Brasil. Construiu-se uma base centrada no indivíduo a partir de dados da Agência Nacional de Saúde Suplementar (ANS); informações sobre beneficiários do Brasil foram consultadas no Departamento de Informática do SUS (DATASUS). Utilizou-se distribuições de frequências para resumir os dados, padronização por idade e sexo para características dos planos privados de saúde e modalidade das operadoras, e razão para comparar frequências. Um total de 31.941 beneficiários realizou hemodiálise no SUS, 11.147 (34,9%) destes fora de seu município de residência, e 6.423 (20,11%) utilizaram o SUS por 25 meses ou mais. Comparados aos demais beneficiários do Brasil, aqueles que realizaram hemodiálise no SUS estavam vinculados mais frequentemente a planos privados de saúde antigos (razão, r = 2,41), coletivos por adesão (r = 1,76), individuais/familiares (r = 1,36), ambulatoriais (r = 4,66), municipais (r = 3,88) e/ou a filantropias (r = 7,32). Planos privados de saúde com características restritivas podem ter dificultado o acesso dos beneficiários que realizaram hemodiálise no SUS às redes de suas operadoras, e representado mais um fator que pode ter influenciado o uso do SUS por aqueles beneficiários, mesmo com a cobertura prevista em seus contratos.

Reimbursement to Brazilian Unified National Health System (SUS) is the most visible interface of the public-private relationship and its analysis can expand our understanding of the use of SUS by the supplementary sector. The study aims to characterize the beneficiaries of private health plans who underwent hemodialysis in the SUS, from 2012 to 2019, in relation to: gender, age group, region of residence, characteristics of the private health plans and the operators and of the care provided to them. The characteristics of the private health plans and the modality of the operators of the beneficiaries where then compared with data of the other beneficiaries in Brazil. An individual-centered database was constructed based on data from the Brazilian National Supplementary Health Agency (ANS); information on beneficiaries in Brazil was consulted in Brazilian Health Informatics Department (DATASUS). Frequency distributions were used to summarize the data, standardization by age and sex for characteristics of the private health plans and modality of the operators and ratio to compare frequencies. A total of 31,941 beneficiaries underwent hemodialysis in the SUS, 11,147 (34.9%) outside their municipality of residence, and 6,423 (20.11%) used the SUS for 25 months or more. When compared with other beneficiaries in Brazil, those who underwent hemodialysis in the SUS were more frequently linked to old private health plans (ratio, r = 2.41), collective by adherence (r = 1.76), individual/family (r = 1.36), outpatient (r = 4.66), municipal (r = 3.88), and/or philanthropic (r = 7.32). Private health plans with restrictive characteristics may have hindered the access of beneficiaries who performed hemodialysis in SUS to the networks of their operators and have represented one more among the factors that may have influenced the use of SUS by those beneficiaries, even with coverage provided for in their contracts.

El resarcimiento al Sistema Único de Salud (SUS) es la interfaz más visible de la relación público-privada y su análisis puede ampliar el conocimiento sobre el uso del SUS por el sector suplementario. El estudio tuvo como objetivo caracterizar a los beneficiarios de planes privados de salud que realizaron hemodiálisis en el SUS, entre 2012 y 2019, con relación a: género, rango de edad, región de residencia, características de los planes privados de salud y de los operadores y a la asistencia prestada a ellos; y comparar características de los planes privados de salud y modalidad de los operadores de aquellos beneficiarios con datos de los demás beneficiarios de Brasil. Se construyó una base centrada en el individuo a partir de datos de la Agencia Nacional de Salud Suplementaria (ANS); las informaciones sobre los beneficiarios en Brasil fueron consultadas en el Departamento de Informática del SUS (DATASUS). Se utilizaron distribuciones de frecuencia para resumir los datos, la estandarización por edad y género para las características de los planes privados de salud y la modalidad de los operadores y la relación para comparar frecuencias. Un total de 31.941 beneficiarios se sometieron a hemodiálisis en el SUS, 11.147 (34,9 %) fuera de su municipio de residencia y 6.423 (20,11 %) utilizaron el SUS por 25 meses o más. Comparados a los demás beneficiarios de Brasil, los beneficiarios que se sometieron a hemodiálisis en el SUS estaban vinculados más frecuentemente a planes privados de salud antiguos (razón, r = 2,41), colectivos por adhesión (r = 1,76), individuales/familiares (r = 1,36), ambulatorios (r = 4,66), municipales (r = 3,88) y/o a filantropías (r = 7,32). Planes privados de salud con características restrictivas pueden haber dificultado el acceso de los beneficiarios que realizaron hemodiálisis en el SUS a las redes de sus operadores y pueden haber representado un factor más entre los que pueden haber influido en el uso del SUS por aquellos beneficiarios, incluso con cobertura prevista en sus contratos.

[Timely outpatient treatment of cervical cancer: the influence of region of residence for women in the state of Minas Gerais, Brazil]. / Tratamento ambulatorial do câncer do colo do útero em tempo oportuno: a influência da região de residência de mulheres no Estado de Minas Gerais, Brasil.

This study aimed to investigate whether there is an association between the Extended Health Regions (EHR) of residence in the state of Minas Gerais, Brazil, and the interval between diagnosis and start of treatment for women who underwent outpatient treatment (chemotherapy or radiotherapy) for cervical cancer by the Brazilian Unified National Health System (SUS), between 2001 and 2015. This is a cross-sectional study, part of a cohort with 8,857 women. Negative binomial regression models were used to evaluate the association of EHR of residence and the interval between diagnosis and start of treatment (in days), considering a significance level of 5%. The models were constructed using blocks of sociodemographic, clinical, and treatment-related covariates. It was found that the EHR of residence of women is associated with the interval between diagnosis and start of treatment. The northern EHR was the region of the state where the average time to start treatment was lower, and not residing in this EHR increases the average time to start treatment between 24% and 93% compared to other EHRs in the state. The disparity in the interval between diagnosis and start of treatment between the regions of Minas Gerais is evident. The availability of services enabled for the treatment of cancer in the EHRs does not necessarily results in a greater agility for the start of treatment. Understanding the flows of Oncology Care Networks and their regional differences is essential to improve public policies that ensure compliance with current laws, such as Law n. 12,732/2012, which recommends the start of treatment for cancer patients within 60 days after diagnosis.

O objetivo deste estudo é investigar se há associação entre as Regiões Ampliadas de Saúde (RAS) de residência de Minas Gerais, Brasil, e o intervalo entre diagnóstico e início de tratamento de mulheres que realizaram tratamento ambulatorial (quimioterapia ou radioterapia) para câncer do colo do útero pelo Sistema Único de Saúde (SUS), entre 2001 e 2015. Trata-se de um estudo transversal, recorte de uma coorte, com 8.857 mulheres. Para avaliar a associação da RAS de residência e o intervalo entre diagnóstico e início de tratamento (em dias), foram utilizados modelos de regressão binomial negativa, considerando nível de significância de 5%. Os modelos foram construídos usando blocos de covariáveis sociodemográficas, clínicas e relacionadas ao tratamento. Foi determinado que a RAS de residência das mulheres está associada ao intervalo entre o diagnóstico e o início de tratamento. A RAS Norte foi a região do estado onde a média de tempo para iniciar o tratamento foi menor, e não residir nessa RAS aumenta a média de tempo para iniciar o tratamento entre 24% e 93% em comparação com outras RAS do estado. Fica evidente a disparidade no intervalo entre diagnóstico e início de tratamento entre as regiões do Estado de Minas Gerais. A disponibilidade de serviços habilitados para o tratamento do câncer nas RAS não reflete necessariamente em maior agilidade para início de tratamento. Compreender os fluxos das Redes de Atenção Oncológica e suas diferenças regionais é fundamental para aprimorar políticas públicas que garantam o cumprimento de leis vigentes, como a Lei nº 12.732/2012, que preconiza o início do tratamento de pacientes com câncer em até 60 dias após o diagnóstico.

El objetivo de este estudio es investigar si existe una asociación entre las Regiones Ampliadas de Salud (RAS) de residencia en Minas Gerais, Brasil, y el intervalo entre el diagnóstico y el inicio del tratamiento para mujeres que realizaron tratamiento ambulatorio (quimioterapia o radioterapia) para cáncer de cuello uterino por el Sistema Único de Salud (SUS) entre 2001 y 2015. Se trata de un estudio transversal, recortado de una cohorte, con 8.857 mujeres. Para evaluar la asociación entre la RAS de residencia y el intervalo entre el diagnóstico y el inicio del tratamiento (en días), se utilizaron modelos de regresión binomial negativa, considerando el nivel de significancia del 5%. Los modelos se construyeron utilizando bloques de covariables sociodemográficas, clínicas y relacionadas con el tratamiento. Se encontró una asociación entre la RAS de residencia de las mujeres y el intervalo entre el diagnóstico y el inicio del tratamiento. La región de la RAS Norte tuvo tiempo promedio más corto para el inicio del tratamiento, pero si las mujeres no residen en esta RAS el tiempo promedio para el inicio del tratamiento puede aumentar entre el 24% y el 93% en comparación con otras RAS del estado. Queda evidente la disparidad del intervalo entre el diagnóstico y el inicio del tratamiento entre las regiones de Minas Gerais. La disponibilidad de servicios habilitados para el tratamiento del cáncer en la RAS no necesariamente refleja la mayor rapidez para el inicio del tratamiento. Es fundamental comprender los flujos de las Redes de Atención Oncológica y sus diferencias regionales para buscar mejorar las políticas públicas que garantizan el cumplimiento de la legislación vigente, como la Ley nº 12.732/2012, que recomienda que el tratamiento de los pacientes con cáncer debe empezar dentro de los 60 días posteriores al diagnóstico.

All-cause and cause-specific mortality among people with severe mental illness in Brazil's public health system, 2000-15: a retrospective study.

BACKGROUND: People with severe mental illness have a mortality rate higher than the general population, living an average of 10-20 years less. Most studies of mortality among people with severe mental illness have occurred in high-income countries (HICs). We aimed to estimate all-cause and cause-specific relative risk (RR) and excess mortality rate (EMR) in a nationwide cohort of inpatients with severe mental illness compared with inpatients without severe mental illness in a middle income country, Brazil. METHODS: This national retrospective cohort study included all patients hospitalised through the Brazilian Public Health System (Sistema Único de Saúde [SUS]-Brazil) between Jan 1, 2000, and April 21, 2015. Probabilistic and deterministic record linkages integrated data from the Hospital Information System (Sistema de informações Hospitalares) and the National Mortality System (Sistema de Informação sobre Mortalidade). Follow-up duration was measured from the date of the patients' first hospitalisation until their death, or until April 21, 2015. Severe mental illness was defined as schizophrenia, bipolar disorder, or depressive disorder by ICD-10 codes used for the admission. RR and EMR were calculated with 95% CIs, comparing mortality among patients with severe mental illness with those with other diagnoses for patients aged 15 years and older. We redistributed deaths using the Global Burden of Diseases, Injuries, and Risk Factors Study methodology if ill-defined causes of death were stated as an underlying cause. FINDINGS: From Jan 1, 2000, to April 21, 2015, 72 021 918 patients (31 510 035 [43·8%] recorded as male and 40 974 426 [56·9%] recorded as female; mean age 41·1 (SD 23·8) years) were admitted to hospital, with 749 720 patients (372 458 [49·7%] recorded as male and 378 670 [50·5%] as female) with severe mental illness. 5 102 055 patient deaths (2 862 383 [56·1%] recorded as male and 2 314 781 [45·4%] as female) and 67 485 deaths in patients with severe mental illness (39 099 [57·9%] recorded as male and 28 534 [42·3%] as female) were registered. The RR for all-cause mortality in patients with severe mental illness was 1·27 (95% CI 1·27-1·28) and the EMR was 2·52 (2·44-2·61) compared with non-psychiatric inpatients during the follow-up period. The all-cause RR was higher for females and for younger age groups; however, EMR was higher in those aged 30-59 years. The RR and EMR varied across the leading causes of death, sex, and age groups. We identified injuries (suicide, interpersonal violence, and road injuries) and cardiovascular disease (ischaemic heart disease) as having the highest EMR among those with severe mental illness. Data on ethnicity were not available. INTERPRETATION: In contrast to studies from HICs, inpatients with severe mental illness in Brazil had high RR for idiopathic epilepsy, tuberculosis, HIV, and acute hepatitis, and no significant difference in mortality from cancer compared with inpatients without severe mental illness. These identified causes should be addressed as a priority to maximise mortality prevention among people with severe mental illness, especially in a middle-income country like Brazil that has low investment in mental health. FUNDING: Bill and Melinda Gates Foundation, Fundação de Amparo a Pesquisa do Estado de Minas Gerais, FAPEMIG, and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-Brasil.

Factors associated with risk of death by suicide after psychiatric hospitalization by the Unified Health System in Brazil (2002-2015).

OBJECTIVE: To investigate overall and sex-related characteristics associated with the risk of death by suicide within 365 days of discharge in patients admitted to psychiatric hospitals in the Brazilian Unified Health System (SUS). METHOD: A non-concurrent prospective cohort of adult patients admitted to psychiatric hospitals in the SUS, from 2002 to 2015. Patients were stratified according to sociodemographic and clinical variables. Adjusted hazard ratios (aHRs) of suicide within 365 days of discharge were estimated using Cox proportional hazard regression models. RESULTS: This sample comprised 1,228,784 adult patients admitted to psychiatric hospitals. Of these, 3201 died by suicide within 365 days of discharge. The risk of suicide was positively associated with male sex, age between 18 and 29 years, living in the South region, and living in rural or intermediate municipalities. The highest risk of suicide was among patients with depressive disorders (aHR, 3.87; 95%CI, 3.41-4.38) follow by opioid-related disorders (aHR, 2.71; 95%CI, 2.00-3.67), particularly among female patients. CONCLUSION: Patients with a psychiatric hospital admission should have access to mental health care services immediately after discharge and in the long term. Findings of this study may support suicide prevention policies and have implications for clinical decisions related to patient discharge and follow-up.

Factors associated with time to initiate lung cancer treatment in Minas Gerais, Brazil. / Fatores associados ao tempo para o início do tratamento do câncer de pulmão em Minas Gerais, Brasil.

The aim was to verify the association of individual factors and healthcare system characteristics with time to initiate treatment of lung cancer by the Brazilian National Health System, in Minas Gerais state. A retrospective cohort study, with patients who initiated treatment for lung cancer by the SUS, from 2008 to 2015. Sociodemographic and clinical characteristics of patients, besides organizational variables of the healthcare system were selected. The logistic regression model evaluated the association of selected explanatory variables with the outcome of initiating treatment within 60 days after diagnosis. Odds ratio (OR) and respective 95% confidence interval were used to measure the power of association. Most treatments for lung cancer in the state of Minas Gerais initiated within 60 days after diagnosis. However, being male and diagnosed as stage IV increased the likelihood of starting treatment within 60 days. On the other hand, the patient's age, radiation therapy as first treatment, and the place of residence decreased such chance. Time to initiate treatment is associated with individual characteristics and provision of services in macroregions, and the observed inequalities possibly raised from the better or worse access of the population to the services provided by SUS.

O objetivo foi verificar a associação entre fatores individuais e organizativos do sistema de saúde com o tempo para o início do tratamento do câncer de pulmão pelo Sistema Único de Saúde (SUS) em Minas Gerais. Estudo de coorte retrospectiva com pacientes que iniciaram o tratamento para o câncer de pulmão pelo SUS de 2008 a 2015. Foram selecionadas variáveis sociodemográficas, clínicas e organizativas do sistema de saúde. O modelo de regressão logística avaliou a associação do desfecho do início do tratamento em até 60 dias após o diagnóstico com as variáveis explicativas selecionadas. Utilizou-se a odds ratio (OR) e o respectivo intervalo de confiança (95%) para mensurar a força de associação. A maioria dos tratamentos para o câncer de pulmão em Minas Gerais foram iniciados em até 60 dias após o diagnóstico, entretanto, ser do sexo masculino e diagnosticado em estadiamento IV aumentaram a chance de iniciar o tratamento em até 60 dias; todavia o aumento da idade, iniciar o tratamento por radioterapia, e o local de residência, diminuíram. O tempo para início do tratamento está associado a características individuais e à provisão de serviços nas macrorregiões, e as desigualdades observadas possivelmente se originam a partir do melhor ou pior acesso da população aos serviços prestados.

Fatores associados ao tempo para o início do tratamento do câncer de pulmão em Minas Gerais, Brasil / Factors associated with time to initiate lung cancer treatment in Minas Gerais, Brazil

Resumo O objetivo foi verificar a associação entre fatores individuais e organizativos do sistema de saúde com o tempo para o início do tratamento do câncer de pulmão pelo Sistema Único de Saúde (SUS) em Minas Gerais. Estudo de coorte retrospectiva com pacientes que iniciaram o tratamento para o câncer de pulmão pelo SUS de 2008 a 2015. Foram selecionadas variáveis sociodemográficas, clínicas e organizativas do sistema de saúde. O modelo de regressão logística avaliou a associação do desfecho do início do tratamento em até 60 dias após o diagnóstico com as variáveis explicativas selecionadas. Utilizou-se a odds ratio (OR) e o respectivo intervalo de confiança (95%) para mensurar a força de associação. A maioria dos tratamentos para o câncer de pulmão em Minas Gerais foram iniciados em até 60 dias após o diagnóstico, entretanto, ser do sexo masculino e diagnosticado em estadiamento IV aumentaram a chance de iniciar o tratamento em até 60 dias; todavia o aumento da idade, iniciar o tratamento por radioterapia, e o local de residência, diminuíram. O tempo para início do tratamento está associado a características individuais e à provisão de serviços nas macrorregiões, e as desigualdades observadas possivelmente se originam a partir do melhor ou pior acesso da população aos serviços prestados.

Abstract The aim was to verify the association of individual factors and healthcare system characteristics with time to initiate treatment of lung cancer by the Brazilian National Health System, in Minas Gerais state. A retrospective cohort study, with patients who initiated treatment for lung cancer by the SUS, from 2008 to 2015. Sociodemographic and clinical characteristics of patients, besides organizational variables of the healthcare system were selected. The logistic regression model evaluated the association of selected explanatory variables with the outcome of initiating treatment within 60 days after diagnosis. Odds ratio (OR) and respective 95% confidence interval were used to measure the power of association. Most treatments for lung cancer in the state of Minas Gerais initiated within 60 days after diagnosis. However, being male and diagnosed as stage IV increased the likelihood of starting treatment within 60 days. On the other hand, the patient's age, radiation therapy as first treatment, and the place of residence decreased such chance. Time to initiate treatment is associated with individual characteristics and provision of services in macroregions, and the observed inequalities possibly raised from the better or worse access of the population to the services provided by SUS.

Tratamento ambulatorial do câncer do colo do útero em tempo oportuno: a influência da região de residência de mulheres no Estado de Minas Gerais, Brasil / Timely outpatient treatment of cervical cancer: the influence of region of residence for women in the state of Minas Gerais, Brazil / Tratamiento ambulatorio del cáncer de cuello uterino en un tiempo adecuado: la influencia de la región de residencia de las mujeres en el estado de Minas Gerais, Brasil

O objetivo deste estudo é investigar se há associação entre as Regiões Ampliadas de Saúde (RAS) de residência de Minas Gerais, Brasil, e o intervalo entre diagnóstico e início de tratamento de mulheres que realizaram tratamento ambulatorial (quimioterapia ou radioterapia) para câncer do colo do útero pelo Sistema Único de Saúde (SUS), entre 2001 e 2015. Trata-se de um estudo transversal, recorte de uma coorte, com 8.857 mulheres. Para avaliar a associação da RAS de residência e o intervalo entre diagnóstico e início de tratamento (em dias), foram utilizados modelos de regressão binomial negativa, considerando nível de significância de 5%. Os modelos foram construídos usando blocos de covariáveis sociodemográficas, clínicas e relacionadas ao tratamento. Foi determinado que a RAS de residência das mulheres está associada ao intervalo entre o diagnóstico e o início de tratamento. A RAS Norte foi a região do estado onde a média de tempo para iniciar o tratamento foi menor, e não residir nessa RAS aumenta a média de tempo para iniciar o tratamento entre 24% e 93% em comparação com outras RAS do estado. Fica evidente a disparidade no intervalo entre diagnóstico e início de tratamento entre as regiões do Estado de Minas Gerais. A disponibilidade de serviços habilitados para o tratamento do câncer nas RAS não reflete necessariamente em maior agilidade para início de tratamento. Compreender os fluxos das Redes de Atenção Oncológica e suas diferenças regionais é fundamental para aprimorar políticas públicas que garantam o cumprimento de leis vigentes, como a Lei nº 12.732/2012, que preconiza o início do tratamento de pacientes com câncer em até 60 dias após o diagnóstico.

This study aimed to investigate whether there is an association between the Extended Health Regions (EHR) of residence in the state of Minas Gerais, Brazil, and the interval between diagnosis and start of treatment for women who underwent outpatient treatment (chemotherapy or radiotherapy) for cervical cancer by the Brazilian Unified National Health System (SUS), between 2001 and 2015. This is a cross-sectional study, part of a cohort with 8,857 women. Negative binomial regression models were used to evaluate the association of EHR of residence and the interval between diagnosis and start of treatment (in days), considering a significance level of 5%. The models were constructed using blocks of sociodemographic, clinical, and treatment-related covariates. It was found that the EHR of residence of women is associated with the interval between diagnosis and start of treatment. The northern EHR was the region of the state where the average time to start treatment was lower, and not residing in this EHR increases the average time to start treatment between 24% and 93% compared to other EHRs in the state. The disparity in the interval between diagnosis and start of treatment between the regions of Minas Gerais is evident. The availability of services enabled for the treatment of cancer in the EHRs does not necessarily results in a greater agility for the start of treatment. Understanding the flows of Oncology Care Networks and their regional differences is essential to improve public policies that ensure compliance with current laws, such as Law n. 12,732/2012, which recommends the start of treatment for cancer patients within 60 days after diagnosis.

El objetivo de este estudio es investigar si existe una asociación entre las Regiones Ampliadas de Salud (RAS) de residencia en Minas Gerais, Brasil, y el intervalo entre el diagnóstico y el inicio del tratamiento para mujeres que realizaron tratamiento ambulatorio (quimioterapia o radioterapia) para cáncer de cuello uterino por el Sistema Único de Salud (SUS) entre 2001 y 2015. Se trata de un estudio transversal, recortado de una cohorte, con 8.857 mujeres. Para evaluar la asociación entre la RAS de residencia y el intervalo entre el diagnóstico y el inicio del tratamiento (en días), se utilizaron modelos de regresión binomial negativa, considerando el nivel de significancia del 5%. Los modelos se construyeron utilizando bloques de covariables sociodemográficas, clínicas y relacionadas con el tratamiento. Se encontró una asociación entre la RAS de residencia de las mujeres y el intervalo entre el diagnóstico y el inicio del tratamiento. La región de la RAS Norte tuvo tiempo promedio más corto para el inicio del tratamiento, pero si las mujeres no residen en esta RAS el tiempo promedio para el inicio del tratamiento puede aumentar entre el 24% y el 93% en comparación con otras RAS del estado. Queda evidente la disparidad del intervalo entre el diagnóstico y el inicio del tratamiento entre las regiones de Minas Gerais. La disponibilidad de servicios habilitados para el tratamiento del cáncer en la RAS no necesariamente refleja la mayor rapidez para el inicio del tratamiento. Es fundamental comprender los flujos de las Redes de Atención Oncológica y sus diferencias regionales para buscar mejorar las políticas públicas que garantizan el cumplimiento de la legislación vigente, como la Ley nº 12.732/2012, que recomienda que el tratamiento de los pacientes con cáncer debe empezar dentro de los 60 días posteriores al diagnóstico.

A judicialização na saúde suplementar: uma avaliação das ações judiciais contra uma operadora de planos de saúde, Belo Horizonte, Minas Gerais, 2010-2017 / Judicialization in supplementary health: an evaluation of lawsuits against a health plan operator, Belo Horizonte, Minas Gerais, 2010-2017

RESUMO A judicialização na saúde suplementar supera a que ocorre no setor público, evidenciando a fragilidade de sua regulação e dificultando o acesso aos planos de saúde. Serão analisadas ações judiciais contra uma operadora da saúde suplementar em Belo Horizonte, entre os anos de 2010 e 2017. Analisaramse proces¬sos judiciais por meio de técnica de análise documental. As variáveis foram relativas à natureza do processo judicial, ao perfil dos beneficiários e às características das demandas. A Regressão de Poisson foi utilizada na avaliação de impacto e relevância das variáveis selecionadas, e o software R versão 3.6.1 para os testes de significância. No período de 2010 a 2017, foram movidas 6.090 ações. As principais causas são questões contratuais, negativa de procedimento, órtese/prótese e exames. Planos anteriores à 'Lei dos Planos de Saúde' correspondem a 3% da carteira e 37,4% da judicialização. Este estudo demonstrou que a possibilidade de judicializar é maior entre clientes masculinos, contratos individuais, planos assistidos em rede ampla, sem coparticipação. A judicialização é mais acessível a cidadãos de maior condição econômica. Questões contratuais evidenciam frágil regulação. Adequada regulamentação reduz o desequilíbrio entre clientes e operadoras. A Agência Nacional de Saúde Suplementar precisa exercer sua função reguladora.

ABSTRACT Judicialization in supplementary health surpasses that which occurs in the public sector, evidencing the fragility of its regulation and making access to health plans difficult. Lawsuits against a Supplementary Health operator in Belo Horizonte, between 2010 and 2017, will be analyzed. Legal proceedings were analyzed using a document analysis technique. Variables were related to the nature of the legal process, the profile of the beneficiaries and the characteristics of the demands. Poisson Regression was used to assess the impact and relevance of the selected variables, and the R software version 3.6.1 for the significance tests. In the period from 2010 to 2017, 6090 actions were filed. The main causes are contractual issues, denial of procedure, orthosis/prosthesis and exams. Plans prior to the 'Health Plan Law', correspond to 3% of the portfolio and 37.4% of the judicialization. This study showed that the possibility of taking legal action is greater among male clients, individual contracts, plans assisted in a wide network, without co-participation. Judicialization is more accessible to citizens of higher economic status. Contractual issues show fragile regulation. Adequate regulation reduces the imbalance between customers and operators. The National Supplementary Health Agency needs to exercise its regulatory function.

Estratégias internacionais de flexibilização da regulação da prática de profissionais de saúde em resposta à pandemia da COVID-19: revisão de escopo / Estrategias internacionales de flexibilización de la regulación de la práctica de profesionales de salud en respuesta a la pandemia de la COVID-19: revisión de alcance / International strategies for flexibilization of the regulation of health workforce practices in response to the COVID-19 pandemic: a scoping review

A COVID-19 foi classificada como pandemia pela Organização Mundial da Saúde (OMS) em 11 de março de 2020. Diante da sua acelerada propagação, governantes, comunidades e serviços de saúde estão tendo que agir na mesma velocidade para ampliar a capacidade da força de trabalho em saúde. Este estudo objetivou, a partir do método revisão de escopo [scoping review], identificar as principais estratégias relacionadas a medidas de flexibilização de regulações que regem as práticas de profissionais de saúde que vêm sendo adotadas e/ou recomendadas internacionalmente. O estudo seguiu as etapas propostas pelo Instituto Joanna Briggs. Para a construção da questão de pesquisa, utilizou-se o método PCC (população, conceito e contexto). A busca se baseou nas seguintes bases de dados: PubMed, Scopus e Base de Dados da OMS; e na literatura cinzenta. Foram identificados 36 documentos, classificados nas seguintes estratégias: (1) ampliação de escopo de prática; (2) transferência de funções de uma categoria profissional para outra; (3) autorização para atendimento e faturamento via telemedicina; (4) licenciamento e recrutamento de profissionais não ativos; (5) recrutamento de profissionais de outras regiões/estado; (6) mudanças na formação e oferta de treinamento. Uma das estratégias mais importantes em resposta a situações de escassez de profissionais de saúde tem sido e a disponibilidade para adaptar, ampliar e redistribuir as atividades dos profissionais, de modo a atender as rápidas mudanças. Esta revisão reflete a importância em se realizarem reformas nas regulações profissionais de forma a otimizar a força de trabalho em saúde existente para que esta possa atender às demandas constantes de necessidade da população.

La COVID-19 fue clasificada como pandemia por la Organización Mundial de la Salud (OMS) el 11 de marzo de 2020. Ante su acelerada propagación, gobernantes, comunidades y servicios de salud están teniendo que actuar a la misma velocidad para ampliar la capacidad de la fuerza de trabajo en salud. Este estudio tuvo como objetivo, a partir del método revisión de alcance, identificar las principales estrategias relacionadas con medidas de flexibilización de regulaciones que rigen las prácticas de profesionales de salud que vienen siendo adoptadas y/o recomendadas internacionalmente. El estudio siguió las etapas propuestas por parte del Instituto Joanna Briggs. Para la construcción de la cuestión de investigación, se utilizó el método PCC (población, concepto y contexto). La búsqueda se basó en las siguientes bases de datos: PubMed, Scopus, Base de Datos de la OMS; y en la literatura gris. Se identificaron 36 documentos, clasificados en las siguientes estrategias: (1) ampliación de ámbito de práctica; (2) transferencia de funciones de una categoría profesional a otra; (3) autorización para atención y facturación vía telemedicina; (4) permisos y reclutamiento de profesionales no activos; (5) reclutamiento de profesionales de otras regiones/estado; (6) cambios en la formación y oferta de entrenamiento. Una de las estrategias más importantes en respuesta a situaciones de escasez de profesionales de salud ha sido la disponibilidad para adaptar, ampliar y redistribuir las actividades de los profesionales, de modo que atienda a cambios rápidos. Esta revisión refleja la importancia de que se realicen reformas en las regulaciones profesionales, de forma que se optimice la fuerza de trabajo en salud existente para que esta pueda atender a las demandas de necesidades constantes de la población.

COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. Given its rapid spread, governments, communities, and health services are having to act with the same speed to expand their health workforce capacity. Based on the scoping review method, this study aimed to identify the principal strategies related to measures for flexibilization of regulations on healthcare workers' practices that have been adopted and/or recommended internationally. The study followed the stages proposed by the Joanna Briggs Institute. The research question was developed with the PCC method (population, concept, and context). Searches were performed in PubMed, Scopus, WHO Database, and the gray literature. A total of 36 documents were identified, classified in the following strategies: (1) expansion of scope of practice; (2) shifting of roles from one professional category to another; (3) authorization for patient care and billing via telemedicine; (4) licensing and recruitment of inactive workers; (5) recruitment of workers from other regions/states; and (6) changes in basic training and supply of new training. One of the most important strategies in response to health workforce shortages has been the willingness to adapt, expand, and redistribute workers' activities to deal with rapid changes. This review reflects the importance of reforms in workforce regulation to optimize the existing health workforce so that it can meet the population's constant needs and demands.

A demographic and clinical panorama of a sixteen-year cohort of soft tissue sarcoma patients in Brazil.

Little is known about soft tissue sarcomas (STS) in Brazil, once the federal statistics regarding estimates on incidence and mortality of the most common cancers that affect the Brazilian population currently do not include STS. This study aims to perform a broad evaluation and description of the epidemiological profile, access to treatment and main clinical outcomes of the Brazilian STS patient. A population-based cohort study of 66,825 patients who underwent procedures related to STS treatment registered in the Brazilian public health system (Sistema Único de Saúde, SUS) databases. Median age was 57 years, 30% of them older than 65 years and 50.7% of the cohort was female. The majority, 50,383 patients (75.4%), was diagnosed between 2008 and 2015. Most prevalent anatomic sites were upper and lower limbs (12.6%) and the registry of sarcomas without a specific location comprehended 29.7% of the cohort. The majority of patients resided in the Northeast (40.2% of the patients). Surgery was the first treatment modality in 77.7% of the cases. For survival analysis, only patients with stage and histological grade information were included. The 1-, 5- and 10-year survival rate of the patients was, respectively, 75.4% (95% CI = 74.1-76.7%), 43.4% (95% CI = 41.5-45.5%) and 18.6% (95% CI = 14.8-23.3%).

The scope of practice of primary health care physicians in rural and urban areas in Brazil.

This study aimed to identify differences in the scope of practice of primary care physicians and find the main factors associated with expanded practice in rural and urban areas of Brazil. Data from an online survey with 2,277 primary care physicians, conducted between January and March 2016, were used. Differences regarding activities and procedures performed by physicians per area were verified using Kruskal-Wallis/Dunn's post hoc and chi-square tests. Multivariate linear regression analyses were done using a bootstrap technique to identify the main factors associated with an expanded scope of practice. Regardless of the location, the results showed that the practices of the primary care physicians are below their competences. Rural physicians performed a higher number of procedures and activities compared with their peers from intermediate and urban municipalities. Within the overall sample, the variables related to a broader scope of practice included: male gender, work in rural municipalities, participation in training and continuing education programs and consultation of clinical protocols, articles and books. This study contributes with evidence that the medical scope of practice varies according to location. Recognizing and understanding the differences and associated factors for an expanded scope of practice is necessary to determine the skills and resources required for practice in rural and urban areas, collaborating in proposals of strategies to improve quality and access of health care services.

Quality of life of patients with cancer undergoing chemotherapy in hospitals in Belo Horizonte, Minas Gerais State, Brazil: does individual characteristics matter?

This study aims to evaluate changes in quality of life of cancer patients at the beginning of the first and the second cycle of chemotherapy (CT) in hospitals in Belo Horizonte, Minas Gerais State, Brazil. Longitudinal, prospective, descriptive study with a quantitative approach. We enrolled 230 patients, from a broader cohort, diagnosed with the five most frequent types of cancer (breast, colorectal, cervical, lung, and head and neck), aged 18 years or older, who were initiating CT for the first time. quality of life was assessed with the EORTC QLQ-C30 version 3, applied at the beginning of the first and second chemotherapy cycle. The paired Wilcoxon test was used to identify differences in quality of life between the two time points. A multivariate linear regression analysis was performed using the bootstrap method to investigate potential predictors of global health Status/quality of life. There was a significant increase in patients' emotional function scores (p < 0.001) as well as symptom scores for pain (p = 0.026), diarrhea (p = 0.018), and nausea/vomiting (p < 0.001) after initiation of CT. Widowhood was associated with improvements in the global health Status/quality of life (p = 0.028), whereas the presence of cervical cancer (p = 0.034) and being underweight (p = 0.033) were related to poorer global health status/quality of life scores. CT has detrimental effects on patients' physical health but, on the other hand, it leads to improvements in the emotional domain. Patients' individual characteristics at the beginning of CT are associated with changes in their quality of life. Our study could help identify these characteristics.

Comorbidities and in-hospital death of viral pneumonia adults admitted to SUS (2002-2015).

OBJECTIVE: To identify demographic and clinical characteristics of adult patients hospitalized in the Brazilian Unified Health System (SUS) due to viral pneumonia and investigate the association between some comorbidities and death during hospitalization. METHODS: This retrospective cohort study was conducted with secondary data of adults admitted to SUS due to viral pneumonia between 2002 and 2015. Patient profile was characterized based on demographic and clinical variables. The association between the ten Elixhauser comorbidities and in-hospital death was investigated using Poisson regression models with robust standard errors. Results were quantified as incidence rate ratio (IRR) with 95% confidence intervals (CI), and we built five models using successive inclusion of variables blocks. RESULTS: Hospital admissions for viral pneumonias decreased throughout the study period, and it was observed that 5.8% of hospitalized patients had an in-hospital death. We observed significant differences in demographic and clinical characteristics by comparing individuals who died during hospitalization with those who did not, with the occurrence of one or more comorbidities being more expressive among patients who died. Although not considered risk factors for in-hospital death, chronic pulmonary disease and congestive heart failure were the most common comorbidities. Conversely, IRR for in-hospital death increased with other neurological disorders, diabetes, cancer, obesity, and especially with HIV/AIDS. CONCLUSIONS: Individuals presenting with pulmonary and cardiovascular diseases require proper attention during hospitalization, as well as those with other neurological diseases, diabetes, cancer, obesity, and especially HIV/AIDS. Understanding the influence of chronic diseases on viral infections may support the healthcare system in achieving better outcomes.

[Assessment of Brazilian clinical guidelines in oncology: gaps in drafting, applicability, and editorial independence]. / Avaliação de diretrizes clínicas brasileiras em oncologia: carências no rigor do desenvolvimento, aplicabilidade e independência editorial.

The expansion in the variety of clinical guidelines in oncology is perceptible worldwide, highlighting the need to guarantee the quality of these documents. The study thus aimed to assess the quality of Brazilian national guidelines for treatments of breast, prostate, and colon and rectal cancers. We selected 12 Brazilian guidelines published by four different drafting groups (Ministry of Health, Supplementary Health System, and medical societies and associations), and the AGREE II instrument was applied. In all these guidelines, we identified important weaknesses in more than one Domain, especially low values for "applicability" and "editorial independence". The patterns observed per Domains are more related to the drafting group than the respective clinical conditions. Lower scores in "drafting rigor" and "editorial independence" were obtained by nongovernmental drafting groups, including absence of information or lack of its transparency. Although the "clarity of presentation" in the Ministry of Health guidelines was relatively lower, all the guidelines presented major limitations in "applicability". Consequently, in the overall assessment, none of the guidelines was recommended without modifications, and four were not recommended at all. Finally, it is necessary to upgrade the guidelines according to the underlying evidence ("methodological rigor") and to present the recommended practices in a comprehensible and applicable way ("applicability"), and to mitigate conflicting interests in order to offer cancer patients the best available care in Brazil.

A ampliação da variedade de diretrizes clínicas em oncologia é perceptível em todo o mundo, o que salienta a necessidade de garantir a qualidade destes documentos. Assim, o objetivo do estudo foi avaliar a qualidade de diretrizes nacionais de tratamentos dos cânceres de mama, próstata e de cólon e reto. Foram selecionadas 12 diretrizes brasileiras publicadas por quatro grupos elaboradores distintos (Ministério da Saúde, sistema suplementar de saúde e de sociedades e associações médicas), e aplicado o instrumento AGREE II. Em todas as diretrizes avaliadas foram identificadas fragilidades importantes em mais de um Domínio, com destaque para os baixos valores para "aplicabilidade" e "independência editorial". Os padrões observados por Domínios apresentam-se mais relacionados com o grupo elaborador do que com as condições clínicas tratadas. Menores escores no "rigor do desenvolvimento" e "independência editorial" foram obtidos por grupos elaboradores não governamentais, inclusive com ausência ou falta de transparência nas informações. Mesmo que a "clareza da apresentação" das diretrizes do Ministério da Saúde tenha sido relativamente inferior, na "aplicabilidade" todas apresentaram limitações expressivas. Consequentemente, na avaliação global nenhuma das diretrizes foi recomendada sem modificações, sendo quatro delas não recomendadas. Por fim, é necessário qualificar as recomendações no que tange as evidências que as fundamentam ("rigor metodológico"), assim como dispor de forma compreensível e exequível as condutas a serem adotadas ("aplicabilidade") e mitigar interesses conflitantes, para que seja ofertado o melhor cuidado aos pacientes oncológicos no país.

La ampliación de la variedad de directrices clínicas en oncología es perceptible en todo el mundo, lo que resalta la necesidad de garantizar la calidad de estos documentos. Por este motivo, el objetivo de este estudio fue evaluar la calidad de directrices nacionales de tratamientos de los cánceres de mama, próstata, así como de colon y recto. Se seleccionaron doce directrices brasileñas, publicadas por cuatro grupos elaboradores distintos (Ministerio de Salud, sistema suplementario de salud, así como sociedades y asociaciones médicas), y se aplicó el instrumento AGREE II. En todas las directrices evaluadas se identificaron debilidades importantes en más de un Dominio, destacando los bajos valores para la "aplicabilidad" e "independencia editorial". Los patrones observados por Dominios se presentan más relacionados con el grupo elaborador, que con las condiciones clínicas tratadas. Menores puntuaciones en el "rigor del desarrollo" e "independencia editorial" se obtuvieron por parte de grupos elaboradores no gubernamentales, inclusive con ausencia o falta de transparencia en la información. A pesar de que la "claridad de la presentación" de las directrices del Ministerio de la Salud haya sido relativamente inferior en la "aplicabilidad", todas presentaron limitaciones expresivas. Consecuentemente, en la evaluación global, ninguna de las directrices fue recomendada sin modificaciones, siendo cuatro de ellas no recomendadas. Por fin, se hace necesario cualificar las recomendaciones, en lo que se refiere a las evidencias que las fundamentan ("rigor metodológico"), así como disponer de forma comprensible y factible las conductas que deben ser adoptadas ("aplicabilidad"), al igual que mitigar intereses conflictivos, para que sea ofertado el mejor cuidado a los pacientes oncológicos en el país.

Sixteen Years of Heart Transplant in an Open Cohort in Brazil: Analysis of Graft Survival of Patients using Immunosuppressants. / Dezesseis Anos de Transplante Cardíaco em Coorte Aberta no Brasil: Análise de Sobrevivência de Pacientes em Uso de Imunossupressores.

BACKGROUND: Heart transplant is the main therapeutic alternative for advanced heart failure patients. Several risk factors affect these patients' survival; however, few studies about the topic are available in Brazil. OBJECTIVES: To review the survival rates of heart transplant patients in the Brazilian Public Health System (Sistema Único de Saúde - SUS) between 2000 and 2015. METHODS: This is a non-concurrent, open cohort study, involving cardiac transplant patients in Brazil. The cumulative survival probability was estimated by the Kaplan-Meier curve, and the curve comparison was done using the Log-Rank test. The Cox model was used to calculate the Hazard-Ratio (HR). Analyses were conducted at the 95% confidence level. RESULTS: The heart transplant survival rate median in Brazil, during the period, was 8.3 years. Each additional year in the recipient's age, the occurrence of infections, and the performance of the surgical procedure in the South Region were associated with a higher risk of graft loss. A higher use ratio of immunosuppressants mycophenolate and azathioprine acted as a protection factor. CONCLUSIONS: The analyses conducted provide the first information about the median survival time in heart transplant patients in Brazil. The difference noticed among the geographical regions may be related to the different treatment protocols adopted in the country, especially in the early 2000s. The rate of mycophenolate and azathioprine use as a protection factor suggests that, despite the absence of differences among therapeutic strategies, use of these drugs may favor survival of certain patients. The study provides robust epidemiological data, which are relevant for public health.

FUNDAMENTO: O transplante cardíaco é a principal alternativa terapêutica para pacientes com insuficiência cardíaca avançada. Diversos fatores de risco influenciam a sobrevivência desses pacientes, entretanto, poucos estudos acerca do tema estão disponíveis no Brasil. OBJETIVOS: Analisar a sobrevivência de pacientes transplantados cardíacos pelo Sistema Único de Saúde no Brasil entre 2000-2015. MÉTODOS: Trata-se de uma coorte não concorrente, aberta, de pacientes transplantados cardíacos no Brasil. A probabilidade acumulada de sobrevivência foi estimada por Kaplan-Meier e a comparação entre as curvas realizada pelo Teste de Log-Rank. O modelo de Cox foi utilizado para calcular o Hazard-Ratio (HR). As análises foram realizadas ao nível de 95% de confiança. RESULTADOS: A mediana de sobrevivência do transplante cardíaco no Brasil no período foi 8,3 anos. Cada ano adicional na idade do receptor, a ocorrência de infecções e a realização do procedimento cirúrgico na região Sul relacionaram-se ao maior risco de perda do enxerto. Maior proporção de uso dos imunossupressores micofenolato e azatioprina atuou como fator protetor. CONCLUSÕES: As análises realizadas fornecem a primeira informação quanto ao tempo de sobrevivência mediana do transplante cardíaco no Brasil. A diferença observada entre as regiões pode estar relacionada aos diferentes protocolos de tratamento adotados no país, principalmente no início dos anos 2000. A proporção de uso de micofenolato e azatioprina como fator protetor sugere que, apesar de não haver diferença entre as estratégias terapêuticas, o uso desses medicamentos pode favorecer a sobrevida de determinados pacientes. O estudo apresenta dados epidemiológicos robustos e importantes para a saúde pública.

Psychiatric hospitalizations by the Unified Health System in Brazil between 2000 and 2014.

OBJECTIVE: To characterize the profile of patients hospitalized for mental and behavioral disorders by the Unified Health System (SUS) in Brazil between 2000 and 2014, and to verify how aspects of the new mental health policy influenced the rate of hospitalized patients in that period. METHODS: Non-concurrent prospective cohort study using secondary data from inpatients with a primary diagnosis of mental and behavioral disorders between 01/01/2000 and 12/31/2014. Sociodemographic, clinical, and hospital characteristics variables were selected. Overall rates of hospitalized patients were calculated according to reason for admission, type of hospital, legal nature, and number of admissions per year for each patient. The association between rates of hospitalized patients, number of psychiatric beds per year, and number of Psychosocial Care Centers per year were tested. RESULTS: We selected a total of 1,549,298 patients, whose most frequent diagnoses on first admission were psychoactive substance use disorders, followed by schizophrenia and mood disorders. The median of hospitalizations per patient was 1.9 and the length of stay per patient was 29 days. The overall rate of hospitalized patients was reduced by almost half in the period. The number of beds per year was positively associated with the rates of hospitalized patients; the number of CAPS per year was negatively associated with some rates of hospitalized patients. CONCLUSION: Even in the face of adversity, the National Mental Health Policy has advanced in its goal of progressively reducing hospital beds and increasing the supply of substitute services such that both strategies were associated with the reduced inpatient rates. But the changes were felt with greater intensity in the first years of the policy's implementation, becoming less pronounced in recent years.

Regional inequalities in cervical cancer survival in Minas Gerais State, Brazil.

BACKGROUND: Cervical cancer survival is marked by socioeconomic and demographic inequalities. We investigated differences in survival across health regions in Minas Gerais, Brazil, in cervical cancer patients who underwent treatment in the Brazilian Public Health System. METHODS: From a database developed through probabilistic and deterministic linkage of data from information systems of the Brazilian Public Health System, we identified cervical cancer cases, diagnosed between 2002 and 2010, who underwent radiation and/or chemotherapy and lived in Minas Gerais, Brazil. Five-year overall and cause-specific survivals were estimated by the Kaplan-Meier method and compared using the log-rank test. We used extended Cox models to assess the relationship between the health region of residence and the overall and cause-specific death risk, adjusting for relevant variables. RESULTS: We included 5613 patients with a median age of 55.0 years. Median follow-up time was 70.0 months. Five-year overall and cause-specific survivals were 56.3 % and 63.6 %, respectively. Across the 13 health regions, 5-year survival ranged from 46.6%-64.2% (p < 0.001) in the overall analysis and from 52.0% to 72.0% (p < 0.001) in the cause-specific analysis. Multivariate models revealed a significantly higher death risk for most health regions in comparison to the reference health region (Norte). Adjustment by age, tumor stage, comorbidity, treatment, travel time, and year of diagnosis had little effect on the association. CONCLUSION: We found regional disparities in cervical cancer survival that persisted after relevant adjustments. Uneven regional provision of health services might be implicated in these disparities, affecting timely access to treatment for cervical cancer patients.