Availability of Genetic Tests in Public Health Services in Brazil: Data from the Brazilian Rare Diseases Network.

INTRODUCTION: The Brazilian Policy for Comprehensive Care for People with Rare Diseases (BPCCPRD) was published in 2014, accrediting several reference centers and incorporating many genetic tests for the diagnosis of rare diseases (RDs). The Brazilian Network of Rare Diseases (RARAS) comprises more than 40 institutions that offer diagnosis and treatment for RDs in Brazil. This network includes Reference Services for Rare Diseases (RDRS), Reference Services for Newborn Screening (NSRS), and University Hospitals distributed in all Brazilian regions. OBJECTIVE: The aim of the study was to map the availability and distribution of the BPCCPRD diagnostic procedures in the Brazilian Unified Health System through RARAS. METHOD: Data were collected through a questionnaire on the Research Electronic Data Capture platform, with 22 questions regarding the availability of procedures. Thirty-seven coordinators from RARAS participating centers received the questionnaire link for participation by email from August/2020 to March/2021. All participating institutions ethically approved this project. RESULTS: Of the 37 institutions, 23 (62.16%) offered cytogenetic tests, 20 (54.05%) offered molecular procedures, and 22 (59.46%) offered inborn errors of metabolism diagnostic tests. The Southern blot analysis, enzyme assays on cultured tissue and urinary organic acid tests had the highest outsourcing rate. On the other hand, the procedures most frequently performed on-site were bone marrow karyotype and long-term cultured karyotype. It was observed that 10 of the 37 centers (27%) did not provide access to investigated procedures (on-site or outsourced). The North and Midwest regions stood out in terms of the unavailability of such techniques in at least 40% of the evaluated institutions. DISCUSSION AND CONCLUSION: This study reveals large discrepancies in the supply of diagnostic procedures in the Brazilian territory. Moreover, there is a broad collaboration between services through the outsourcing of multiple diagnostic techniques to address this issue. Finally, this work corroborates the importance of mapping services for the diagnosis and treatment of individuals with RDs to propose actions for the better supply and distribution of these procedures.

O processo regulatório do exercício da acupuntura no Brasil: dilemas e conflitos / The regulatory process of acupuncture practice in Brazil: dilemmas and conflicts

Embora muitas das técnicas da medicina tradicional chinesa sejam praticadas atualmente nos serviços do Sistema Único de Saúde, a regulamentação da acupuntura no Brasil é conflituosa e marcada por disputas judiciais. Envolvidas nas disputas em torno do exercício profissional dessas práticas estão autarquias federais e entidades profissionais da saúde. O presente artigo analisou a constituição dos discursos de atores envolvidos no processo de regulamentação da acupuntura no Brasil em um recorte temporal histórico, referente ao período de 2000 a 2012. Foram pesquisados 228 textos nos sites institucionais de 39 entidades ligadas à medicina tradicional chinesa e, particularmente, à acupuntura. Os textos foram submetidos à análise de discurso conforme a abordagem de Dominique Maingueneau. As formações discursivas da acupuntura médica e da acupuntura multiprofissional configuram entendimentos distintos sobre a institucionalização dessa prática. A ausência de um consenso sobre a delimitação do campo de atuação do acupunturista é um obstáculo considerável para a regulamentação da prática. As questões ético-legais das delimitações do campo de atuação, a criação de diretrizes para ensino e pesquisa e o estabelecimento de parâmetros de segurança, qualidade e eficácia são desafios para a implementação da acupuntura nos serviços de saúde.

Although many of the techniques of traditional Chinese medicine are currently practiced in the Brazilian Public Health System health services, the regulation of acupuncture in Brazil is conflicting and marked by legal disputes between federal authorities and health professionals about the professional practice of this health practice. The presente article aimed to analyse the constitution of the different discourses of actors involved in the process of acupuncture regulation in Brazil in a historical timeframe of this trajectory, from 2000 to 2012. 228 texts were collected from the institutional websites of 39 entities related to traditional Chinese medicine and acupuncture. Texts were submit ted to the discourse analysis of Dominique Maingueneau. The discursive formations of medical acupuncture and multidisciplinary acupuncture constitute different understandings about the institutionalization of acupuncture. The absence of a consensus on the delimitation of the acupuncturist's field of action is a considerable obstacle to the regulation of the practice. The ethical-legal dilemmas of the field boundaries, the creation of guidelines for teaching and research and the establishment of safety, quality and efficacy parameters are challenges for the implementation of acupuncture in health services.

O direito à internação psiquiátrica no sistema de saúde brasileiro: as representações sociais do Tribunal de Justiça de São Paulo / The right to psychiatric admission in the Brazilian health system: the São Paulo Court of Justice' social representations

Este artigo teve como objetivo analisar as representações sociais do Tribunal de Justiça de São Paulo sobre o direito à internação psiquiátrica no sistema de saúde brasileiro. Os dados foram coletados do sítio eletrônico do tribunal paulista, a partir de 184 acórdãos de ações julgadas em segunda instância, proferidos em razão de recursos de apelação e publicados no período de janeiro de 1998 a dezembro de 2012, referentes às internações psiquiátricas pleiteadas no Sistema Único de Saúde e no sistema de saúde suplementar. Os métodos empregados para análise dos resultados foram a estatística descritiva e o discurso do sujeito coletivo. Aplicou-se, ainda, a Teoria das Representações Sociais como referencial teórico de interpretação dos discursos elaborados. No Sistema Único de Saúde, a internação reclamada em juízo foi a compulsória, representada, majoritariamente, como medida de proteção da dignidade da pessoa com transtorno mental e, minoritariamente, como violência contra essa mesma dignidade. No sistema suplementar, a representação judicial assumiu o enfoque consumerista, consubstanciado na abusividade da cláusula limitativa da internação psiquiátrica e no direito superior à vida. O direito à saúde, vislumbrado nas decisões judiciais, resumiu-se ao direito de acesso aos serviços de saúde e ao direito à doença. A compreensão do Poder Judiciário, nos dois sistemas investigados, foi a do direito à saúde como o direito ao bem de saúde pleiteado em juízo, o que coloca muitos desafios para os sistemas de saúde e para o Poder Judiciário frente à consolidação dos ideais da reforma psiquiátrica estatuída pela Lei n. 10.216/2001.

The current research sought to present the social representations of judges from the São Paulo Court of Justice about the law regarding psychiatric admissions. Data were collected through the court website, from 184 judgments including all the decisions published between January 1998, and December 2012, regarding psychiatric admissions claimed to both the Brazilian Public Health System, and the private insurance health system. As methods, the author used descriptive statistics and the collective subject speech. The Social Representations Theory was applied as a theoretical framework to interpret the collected speeches. Considering Brazilian Public Health System, the admissions claimed on the court were compulsory and judges presented the psychiatric admissions, mostly, as a protection measure of people with mental disorders dignity and, at a lower degree, as a violence against this same dignity. With respect to the private insurance health system, the judicial representation was related to the consumerist approach, supported by the abuse of a clause restricting the time for psychiatric admissions and its contradiction with the right to life. The right to health was characterized in the decisions as the right of access to health services and the right to be ill. The comprehension of the judges in both investigated systems related the right to health to the right to a health as a good claimed in court, imposing many challenges to health systems and the Judiciary Power in order to consolidate the principles of the psychiatric reform brought by Law n. 10.216/2001.

Os não nacionais imigrantes e o sistema público de saúde do Brasil: a universalidade do direito à saúde e a pandemia de Covid-19 / Non-national immigrants and the public health system in Brazil: the universality of the right to health and the covid-19 pandemic

O objetivo deste artigo foi investigar o direito humano e fundamental à saúde pública dos não nacionais imigrantes, especificamente durante a pandemia de covid-19. Para cumprir essa proposta, buscou-se compreender o contexto em que os não nacionais imigrantes estão inseridos em nosso país, bem como analisar o atendimento dessa população no âmbito do Sistema Único de Saúde, em especial o preenchimento dos formulários do sistema público em relação aos não nacionais imigrantes no curso da covid-19 no Brasil. A metodologia incluiu análises doutrinária, legislativa e documental a partir de uma abordagem analítico-interpretativa. Concluiu-se que existe, por parte dos poderes públicos, relativo esquecimento dos não nacionais imigrantes. A fim de mitigar essa situação, defendem-se a mudança nos formulários do Sistema Único de Saúde para a inclusão do campo "não nacional", a ampliação dos programas de medicina preventiva, a capacitação dos profissionais de saúde e a criação de canais de diálogo no idioma dos não nacionais imigrantes.

This article aimed to investigate the human and fundamental right to public health of non-national immigrants, specifically during the covid-19 pandemic. To fulfill this proposal, we sought to understand the context in which non-national immigrants are inserted in our country, as well as to analyze the care provided to this population within the scope of the Brazilian Public Health System, in particular the completion of the public system forms in relation to non-nationals. national immigrants during covid-19 in Brazil. The methodology included doctrinal, legislative and document analysis from an analytical-interpretative approach. It was concluded that there is, on the part of public authorities, relative forgetfulness of non-national immigrants. To mitigate this situation, a change in the forms of the Brazilian Public Health System for the inclusion of the "non-national" field, the expansion of preventive medicine programs, and the training of health professionals and the creation of dialogue channels, are advocated. All this, using the language of non-national immigrants.

Quality of life in patients with malignant pleural effusion treated with an indwelling pleural catheter in an emerging country.

BACKGROUND: The use of Indwelling Pleural Catheter (IPC) in the care of patients with Malignant Pleural Effusion (MPE) is well established, however studies involving public health systems of low and middle-income countries are still lacking. This study aimed to determine the effect of IPC on the respiratory symptoms and Quality of Life (QoL) of patients with MPE in the setting of a Brazilian public health system. METHODS: From August 2015 to November 2019, patients with MPE underwent IPC placement and were prospectively followed. QoL and respiratory symptoms were assessed by the EORTC questionnaires (QLQ-30; LC13) and Visual Analogue Scale (VAS), respectively, at pre-treatment, 30 , and 60 days after IPC placement. RESULTS: 56 patients were enrolled with 57 catheters inserted. The mean age was 63 (23‒88) years, of which 17 (30%) were men and 39 (70%) were women. Breast 24 (42%) and lung 21 (37%) were the main primary neoplasms. Cellulitis was the most common complication and all patients recovered with appropriate antimicrobial therapy. QoL did not change significantly over time, however, the VAS showed a significant improvement in dyspnea (+1.2: -0.5; p = 0.001). CONCLUSION: IPC relieves respiratory symptoms without compromising the QoL, with a low complication rate. It represents a suitable option for patients with MPE and short LE in an emerging country.

Prevalence and Factors Associated With Out-of-Pocket Pharmaceutical Expenditure Among Primary Healthcare Patients: Evidence From the Prover Project.

OBJECTIVES: This study aimed to determine the prevalence and associated factors of out-of-pocket pharmaceutical expenditure (OOPPE) among primary healthcare patients. METHODS: The study is part of the Prover Project, an exit survey conducted in 2017 in a large city (population 234 937) in Minas Gerais State, Brazil. A representative sample of patients (n = 1219) from pharmaceutical services based on primary healthcare was selected. Three components of OOPPE were assessed: the general prevalence, the types of medicines purchased (medicines for the treatment of chronic diseases, medicines for the treatment of acute diseases, or herbal medicines), and coverage by the National Health System. The factors associated with OOPPE were examined applying a modified Andersen's behavioral model of health services use. Data were analyzed using descriptive statistics and logistic regression. RESULTS: The overall prevalence of OOPPE was 77%. Most patients who had OOPPE purchased medicines to treat chronic diseases (94%). In addition, these patients purchased medicines covered by public insurance but were out of stock (85%). OOPPE was associated with enabling factors, such as higher personal income (odds ratio [OR] 1.92; 95% confidence interval [CI] 1.02-3.62), holding health insurance (OR 1.40; 95% CI 1.01-1.95), and higher neighborhood trust (OR 1.34; 95% CI 1.01-1.79), and with need factors, that is, poorer perception of health (OR 1.63; 95% CI 1.20-2.21), multiple comorbidities (OR 1.70; 95% CI 1.18-2.46), and higher number of prescribed medicines (OR 2.84; 95% CI 1.90-4.26). CONCLUSIONS: We found a high prevalence of OOPPE, identifying individuals more likely to incur these expenses. These findings are useful to inform policy makers from the healthcare system to plan and implement the needed interventions to protect primary care patients from this financial burden.

Severe Acute Respiratory Syndrome by SARS-CoV-2 Infection or Other Etiologic Agents Among Brazilian Indigenous Population: An Observational Study from the First Year of Coronavirus Disease (COVID)-19 Pandemic.

BACKGROUND: Indigenous peoples are vulnerable to pandemics, including to the coronavirus disease (COVID)-19, since it causes high mortality and specially, the loss of elderly Indigenous individuals. METHODS: The epidemiological data of severe acute respiratory syndrome (SARS) by SARS-CoV-2 infection or other etiologic agents (OEA) among Brazilian Indigenous peoples during the first year of COVID-19 pandemic was obtained from a Brazilian Ministry of Health open-access database to perform an observational study. Considering only Indigenous individuals diagnosed with SARS by COVID-19, the epidemiology data were also evaluated as risk of death. The type of sample collection for virus screening, demographic profile, clinical symptoms, comorbidities, and clinical evolution were evaluated. The primary outcome was considered the death in the Brazilian Indigenous individuals and the secondary outcome, the characteristics of Brazilian Indigenous infected by SARS-CoV-2 or OEA, as the need for intensive care unit admission or the need for mechanical ventilation support. The statistical analysis was done using Logistic Regression Model. Alpha of 0.05. FINDINGS: A total of 3,122 cases of Indigenous individuals with SARS in Brazil were reported during the first year of the COVID-19 pandemic. Of these, 1,994 were diagnosed with COVID-19 and 730/1,816 (40.2%) of them died. The death rate among individuals with SARS-CoV-2 was three-fold increased when compared to the group of individuals with OEA. Several symptoms (myalgia, loss of smell, and sore throat) and comorbidities (cardiopathy, systemic arterial hypertension, and diabetes mellitus) were more prevalent in the COVID-19 group when compared to Indigenous individuals with OEA. Similar profile was observed considering the risk of death among the Indigenous individuals with COVID-19 who presented several symptoms (oxygen saturation <95%, dyspnea, and respiratory distress) and comorbidities (renal disorders, cardiopathy, and diabetes mellitus). The multivariate analysis was significant in differentiating between the COVID-19-positive and non-COVID-19 patients [X2 (7)=65.187; P-value<0.001]. Among the patients' features, the following contributed in relation to the diagnosis of COVID-19: age [≥43 years-old [y.o.]; OR=1.984 (95%CI=1.480-2.658)]; loss of smell [OR=2.373 (95%CI=1.461-3.854)]; presence of previous respiratory disorders [OR=0.487; 95%CI=0.287-0.824)]; and fever [OR=1.445 (95%CI=1.082-1.929)]. Also, the multivariate analysis was able to predict the risk of death [X2 (9)=293.694; P-value<0.001]. Among the patients' features, the following contributed in relation to the risk of death: male gender [OR=1.507 (95%CI=1.010-2.250)]; age [≥60 y.o.; OR=3.377 (95%CI=2.292-4.974)]; the need for ventilatory support [invasive mechanical ventilation; OR=24.050 (95%CI=12.584-45.962) and non-invasive mechanical ventilation; OR=2.249 (95%CI=1.378-3.671)]; dyspnea [OR=2.053 (95%CI=1.196-3.522)]; oxygen saturation <95% [OR=1.691 (95%CI=1.050-2.723)]; myalgia [OR=0.423 (95%CI=0.191-0.937)]; and the presence of kidney disorders [OR=3.135 (95%CI=1.144-8.539)]. INTERPRETATION: The Brazilian Indigenous peoples are in a vulnerable situation during the COVID-19 pandemic and presented an increased risk of death due to COVID-19. Several factors were associated with enhanced risk of death, as male sex, older age (≥60 y.o.), and need for ventilatory support; also, other factors might help to differentiate SARS by COVID-19 or by OEA, as older age (≥43 y.o.), loss of smell, and fever. FUNDING: Fundação de Amparo à Pesquisa do Estado de São Paulo (Foundation for Research Support of the State of São Paulo; #2021/05810-7).

Generalized pustular psoriasis in Brazil: A public claims database study.

BACKGROUND: Generalized pustular psoriasis (GPP) is a rare and severe phenotype of psoriasis characterized by sudden outbreak of widespread coalescent sterile pustules associated with a spectrum of systemic symptoms. OBJECTIVE: We aimed to describe the epidemiology and treatment of GPP in Brazil from the public health care system perspective. METHODS: This was a retrospective public claims database study, using outpatient and inpatient databases, with information from January 2018 to August 2020, based on records of health resource utilization by patients with GPP. Outpatient treatment regimens and fatal inpatient outcomes were described. RESULTS: In total, 1458 outpatients of all ages were identified, of whom 53% were women. We estimated the GPP prevalence in Brazil to be between 0.7 and 0.9 per 100,000. Acitretin was the most commonly dispensed drug. Of all the outpatients, 769 outpatients could be tracked in the inpatient database, and 151 had hospital admissions during the study period. Of them, 5.3% had a fatal outcome during hospitalization. A primary skin condition or an infection was the most frequent hospitalization cause. LIMITATION: The International Classification of Diseases codes for GPP and psoriasis have not been previously validated in this context. CONCLUSION: GPP is a rare disease in Brazil and affects individuals of all ages and both sexes. Hospitalizations and disease-related deaths highlight the need for its prompt diagnosis, close medical follow-up, and effective treatment.

Quality of life in patients with malignant pleural effusion treated with an indwelling pleural catheter in an emerging country

Abstract Background: The use of Indwelling Pleural Catheter (IPC) in the care of patients with Malignant Pleural Effusion (MPE) is well established, however studies involving public health systems of low and middle-income countries are still lacking. This study aimed to determine the effect of IPC on the respiratory symptoms and Quality of Life (QoL) of patients with MPE in the setting of a Brazilian public health system. Methods: From August 2015 to November 2019, patients with MPE underwent IPC placement and were prospectively followed. QoL and respiratory symptoms were assessed by the EORTC questionnaires (QLQ-30; LC13) and Visual Analogue Scale (VAS), respectively, at pre-treatment, 30 , and 60 days after IPC placement. Results: 56 patients were enrolled with 57 catheters inserted. The mean age was 63 (23‒88) years, of which 17 (30%) were men and 39 (70%) were women. Breast 24 (42%) and lung 21 (37%) were the main primary neoplasms. Cellulitis was the most common complication and all patients recovered with appropriate antimicrobial therapy. QoL did not change significantly over time, however, the VAS showed a significant improvement in dyspnea (+1.2: -0.5; p = 0.001). Conclusion: IPC relieves respiratory symptoms without compromising the QoL, with a low complication rate. It represents a suitable option for patients with MPE and short LE in an emerging country. HIGHLIGHTS Indwelling pleural catheter represents a suitable option for patients with malignant pleural effusion and short life expectancy. It relieves respiratory symptoms without compromising the quality of life, and the complication rate is low, even in an emerging country, with a low socioeconomic and under-educated patient population. The rate of spontaneous pleurodesis was 45%. The analysis of the visual analog scale showed significant control of dyspnea (p = 0.001), but pain and quality of life did not change significantly.

O projeto dos planos de saúde acessíveis: prejuízo para beneficiários e para o sistema público / The Accessible Health Insurance Bill: Harm to beneficiaries and the public system

O presente trabalho analisou, sob a perspectiva econômica da concretização do direito à saúde, o Projeto de Lei dos Planos de Saúde Acessíveis (PL n. 7.419/2006), apensado ao projeto geral de reforma da Lei n. 9.656/1998, desenvolvido pelo Ministério da Saúde em 2016 e atualmente em tramitação na Câmara dos Deputados. Para isso, os documentos oficiais da proposta foram analisados à luz de suas justificativas econômicas e da amplitude do acesso a serviços. As principais diretrizes do projeto, destacando-se os novos modelos de planos, evidenciam a criação de entraves burocráticos à realização de procedimentos, além da flexibilização do rol de cobertura dos planos de acordo com a infraestrutura local, em desacordo com a cobertura mínima prevista na regulação atual. A proposta favorece economicamente as operadoras de planos de saúde ao estabelecer a coparticipação de 50% e o reajuste conforme tabela de custos. Além disso, na prática, o projeto apresenta um duplo prejuízo: ao beneficiário, que arca com os custos do plano e, no momento de maior necessidade, de procedimentos de urgência ou de maior complexidade por não estar amparado pela cobertura; e ao sistema público, que deve suprir as deficiências da cobertura privada, o que, em um momento de maior demanda e recursos limitados, pode levá-lo à sobrecarga.

The present work analyzed, from the economic perspective of the realization of the right to health, the Accessible Health Insurance Bill (PL No. 7,419/2006), attached to the general project of reform of Law No. 9,656/1998, developed by the Ministry of Health in 2016 and currently being processed in the Chamber of Deputies. For this, the official documents of the proposal were analyzed in light of its economic justifications and the scope of access to services. The main guidelines of the project, highlighting the new models of plans, show the creation of bureaucratic obstacles to the performance of procedures, in addition to the flexibility of the coverage list of the plans according to the local infrastructure, in disagreement with the minimum coverage in the current regulation. The proposal economically favors the health insurance companies by establishing the 50% coparticipation and adjustment according to the cost table. Moreover, in practice, the project presents a double loss: to the beneficiary, who bears plan costs and, at the moment of greatest need, emergency procedures or of greater complexity, because he is not protected by the coverage; and to the public system, which must supply the deficiencies of private coverage, which, at a time of greater demand and limited resources, can lead to overload.

Thyroid cancer burden and economic impact on the Brazilian public health system

ABSTRACT Objective: Recent data indicates an increasing incidence of thyroid cancer not accompanied by a proportional increase in mortality, suggesting overdiagnosis, which may represent a big public health problem, particularly where resources are scarce. This article aims to describe and evaluate the procedures related to investigation of thyroid nodules and treatment and follow-up of thyroid cancer and the costs for the Brazilian public health system between 2008 and 2015. Materials and methods: Data on procedures related to investigation of thyroid nodules and treatment/follow-up of thyroid cancer between 2008 and 2015 in Brazil were collected from the Department of Informatics of the Brazilian Unified Health System (Datasus) website. Results: A statistically significant increase in the use of procedures related to thyroid nodules investigation and thyroid cancer treatment and follow-up was observed in Brazil, though a reduction was noted for procedures related to the treatment of more aggressive thyroid cancer, such as total thyroidectomy with neck dissection and higher radioiodine activities such as 200 and 250 milicuries (mCi). The procedures related to thyroid nodules investigation costs increased by 91% for thyroid ultrasound (p = 0.0003) and 128% in thyroid nodule biopsy (p < 0.001). Costs related to treatment and follow-up related-procedures increased by 120%. Conclusion: The increase in the incidence of thyroid cancer in Brazil is directly associated with an increased use of diagnostic tools for thyroid nodules, which leads to an upsurge in thyroid cancer treatment and followup-related procedures. These data suggest that substantial resources are being used for diagnosis, treatment and follow-up of a potentially indolent condition.

Organization and functioning of the health gym program in the city of Camaragibe-PE / Organização e funcionamento do programa academia da saúde em Camaragibe-PE

The evaluation of health policies and programs is an important tool for decision-making. Among the instruments used for this purpose, the Logical Model stands out, establishing a visual reference regarding the interaction among the inputs, activities and expected results of an intervention. The present study aimed to evaluate the organization of actions and the functioning of the Programa Academia da Saúde (PAS ­ Health Gym Program) in the city of Camaragibe, Pernambuco state, Northeastern Brazil, using a logical model. Program actions were in line with some guidelines established by the Brazilian Ministry of Health services in relation to other primary care services and promotion of the adoption of active lifestyles by the population. However, they do not comply with the recommendations for work shifts and the professionals' workload at the centers. Camaragibe has the potential to enlarge the scope of multi-professional approaches aimed at comprehensive care

A avaliação de políticas e programas de saúde configura-se como uma importante ferramenta para a tomada de decisão. Entre os instrumentos utilizados para esse fim, destaca-se o Modelo Lógico, o qual estabelece uma referência visual a respeito da articulação entre os insumos, atividades e resultados esperados para uma intervenção. O objetivo deste estudo foi avaliar a organização das ações e o funcionamento do Programa Academia da Saúde (PAS) no município de Camaragibe (Pernambuco) utilizando um modelo lógico. Observou-se que as ações do PAS alinham-se a algumas diretrizes estabelecidas pelo Ministério da Saúde quanto à articulação com outros serviços da atenção primária e incentivo à adoção de estilos de vida ativos por parte da população, porém, não atendem as recomendações quanto aos turnos de funcionamento e carga horária dos profissionais que atuam no polo. As ações do PAS em Camaragibe têm potencial para ampliar o escopo de abordagens multiprofissionais com vistas à integralidade do cuidado.

Cost-effectiveness of insulin analogs from the perspective of the Brazilian public health system

ABSTRACT Human insulin is provided by the Brazilian Public Health System (BPHS) for the treatment of diabetes, however, legal proceedings to acquire insulin analogs have burdened the BPHS health system. The aim of this study was to perform a cost-effectiveness analysis to compare insulin analogs and human insulins. This is a pharmacoeconomic study of cost-effectiveness. The direct medical cost related to insulin extracted from the Ministry of Health drug price list was considered. The clinical results, i.e. reduction in glycated hemoglobin (HbA1c), were extracted by meta-analysis. Different scenarios were structured to measure the uncertainties regarding the costs and reduction in HbA1c. Decision tree was developed for sensitivity of Incremental Cost Effectiveness Ratio (ICER). A total of fifteen scenarios were structured. Given the best-case scenario for the insulin analogs, the insulins aspart, lispro, glargine and detemir showed an ICER of R$ 1,768.59; R$ 3,308.54; R$ 11,718.75 and R$ 2,685.22, respectively. In all scenarios in which the minimum effectiveness was proposed, lispro, glargine and detemir were dominant strategies. Sensitivity analysis showed that the aspart had R$ 3,066.98 [95 % CI: 2339.22; 4418.53] and detemir had R$ 6,163.97 [95% CI: 3919.29; 11401.57] for incremental costs. We concluded there was evidence that the insulin aspart is the most cost-effective.

The utility of the records medical: factors associated with the medication errors in chronic disease / A utilidade do registros médico: fatores associados aos erros de medicamentos em pacientes com doenças crônicas / La utilidad de la historia clínicas: factores asociados a los errores de medicación en la enfermedad crónica

ABSTRACT Objective: This study describes the development of the medication history of the medical records to measure factors associated with medication errors among chronic diseases patients in Diamantina, Minas Gerais. Methods: retrospective, descriptive observational study of secondary data, through the review of medical records of hypertensive and diabetic patients, from March to October 2016. Results: The patients the mean age of patient was 62.1 ± 14.3 years. The number of basic nursing care (95.5%) prevailed and physician consultations were 82.6%. Polypharmacy was recorded in 54% of sample, and review of the medication lists by a pharmacist revealed that 67.0% drug included at least one risk. The most common risks were: drug-drug interaction (57.8%), renal risk (29.8%), risk of falling (12.9%) and duplicate therapies (11.9%). Factors associated with medications errors history were chronic diseases and polypharmacy, that persisted in multivariate analysis, with adjusted RP chronic diseases, diabetes RP 1.55 (95%IC 1.04-1.94), diabetes/hypertension RP 1.6 (95%CI 1.09-1.23) and polypharmacy RP 1.61 (95%IC 1.41-1.85), respectively. Conclusion: Medication errors are known to compromise patient safety. This has led to the suggestion that medication reconciliation an entry point into the systems health, ongoing care coordination and a person focused approach for people and their families.

RESUMO Objetivo: Este estudo descreve o desenvolvimento da história de medicação a partir dos prontuários médicos para medir os fatores associados aos erros de medicamentos em pacientes com doenças crônicas, em Diamantina, Minas Gerais. Métodos: Estudo retrospectivo e observacional de dados secundários, por meio da revisão de prontuários de pacientes hipertensos e diabéticos, de março a outubro de 2016. Resultados: A idade média dos pacientes foi de 62,1±14,3 anos. Prevaleceu o número de atividades de cuidados básicos de enfermagem (95,5%) e as consultas médicas foram de 82,6%. A polifarmácia foi registrada em 54% da amostra e a revisão das listas de medicamentos por um farmacêutico revelou que 67,0% dos medicamentos incluíam pelo menos um risco. Os riscos mais comuns foram: interação entre medicamentos (57,8%), risco renal (29,8%), risco de queda (12,9%) e terapias duplicadas (11,9%). Os fatores associados à história de erros de medicamentos foram doenças crônicas e polifarmácia, que persistiram em análises multivariadas, com razão de prevalência (RP) ajustadas por doenças crônicas, diabetes RP 1.55 (95% IC 1.04-1.94), diabetes/hipertensão RP 1.6 (95% IC 1.09-1.23) e polifarmácia RP 1,61 (95% IC 1,41-1,85), respectivamente. Conclusão: Os erros de medicamentos são conhecidos por comprometer a segurança do paciente. Isso levou à sugestão de que a reconciliação de medicamentos como ponto de entrada nos sistemas de saúde, coordenando com cuidados contínuos e uma abordagem centrada no paciente para pessoas e suas famílias.

RESUMEN Objetivo: Este estudio describe el desarrollo del historial de medicación de las historias clínicas para medir los factores asociados a los errores de medicación en pacientes con enfermedades crónicas en Diamantina, Minas Gerais. Método: estudio retrospectivo, observacional descriptivo de datos secundarios, a través de la revisión de historias clínicas de pacientes hipertensos y diabéticos, de marzo a octubre de 2016. Resultados: La edad media del paciente fue de 62.1 ± 14.3 años. Las actividades de atención básica de enfermería representaron y prevalecieron (95.5%) y las consultas médicas fueron del 82.6%. La polifarmacéutica se registró en el 54% de la muestra, y la revisión de las listas de medicamentos por un farmacéutico reveló que el 67.0% de medicamentos incluía al menos un riesgo. Los riesgos más comunes fueron: interacción entre fármacos (57.8%), riesgo renal (29.8%), riesgo de caída (12.9%) and terapias duplicadas (11.9%). Los factores asociados con el historial de los errores de medicación fueron las enfermedades crónicas y la polifarmacéutica, que persistieron en el análisis multivariante, con enfermedades crónicas RP ajustadas, diabetes RP 1.55 (95%IC 1.04-1.94), diabetes / hipertensión RP 1.6 (95%CI 1.09-1.23) y polifarmacéutica RP 1.61 (95%IC 1.41-1.85), respectivamente. Conclusión: Se sabe que los errores de medicación comprometen la seguridad del paciente. Esto ha llevado a la sugerencia de que la reconciliación de medicamentos es un punto de entrada a la salud de los sistemas, la coordinación de la atención continua y un enfoque centrado en la persona para los pacientes y sus familias.

Assessment of pharmaceutical services in HIV/AIDS health units in the city of Niterói, Brazil

ABSTRACT This study aimed to conduct an assessment of pharmaceutical services in HIV/AIDS in the city of Niteroi, Brazil, with emphasis on management. It was done a descriptive cross-sectional study, and the approach used was a normative assessment focused on quality. The indicators used were analyzed individually or grouped according to the components of pharmaceutical services. The assessment identified some good points, especially regarding the good availability of ARVs, and good guide patients in the use of these drugs, and also some problems such as low levels of compliance in relation to good dispensing practices criteria and storage and a high time for the distribution of medicines. The result was a degree of 50.3% compliance with the quality criteria, considered only regular in accordance with trial made. Proposals were suggested for actions and interventions, especially in relation to the improvement of structural conditions of pharmacies of health facilities in the city, and increased training of professionals involved in the services.

Profile of patients with rheumatic diseases undergoing treatment with anti-TNF agents in the Brazilian Public Health System (SUS), Belo Horizonte - MG

The aim of this study was to describe the baseline demographic and clinical characteristics as well as the functional status of a prospective cohort of patients with rheumatic diseases assisted by the Brazilian Public Health System (SUS). Data for 302 patients receiving tumor necrosis factor α inhibitors (anti-TNF agents) was collected through a standard form. Among patients, 229 (75.8%) were female and 155 (51.3%) were Caucasian; the mean age was 50.3 ± 12.8 years, and the mean disease duration was 9.9 ± 8.7 years. Among them 214 patients (70.9%) received adalimumab, 72 (23.8%) etanercept, and 16 (5.3%) infliximab. Mean Health Assessment Questionnaire-Disability Index (HAQ-DI) was 1.37 ± 0.67 for all participants. Poor functional response was associated with female gender, married patients and with a score of < 0.6 on the EuroQoL-5 dimensions (EQ-5D). Significant correlation was found between the HAQ-DI values, disease activity and quality of life (QOL). The results obtained in this study contribute to a better understanding of the clinical and demographic characteristics of patients with rheumatic diseases at the beginning of anti-TNF-agent treatment by SUS. Furthermore, our findings are consistent with another Brazilian and foreign cross-sectional investigations. This knowledge can be of great importance for further studies evaluating the effectiveness of biological agents, as well as, to contribute to improve the well-being of the patients with rheumatic diseases.

O objetivo do estudo foi descrever as características demográficas e clínicas iniciais, bem como o estado funcional de uma coorte de pacientes com doenças reumáticas tratados pelo Sistema Único de Saúde (SUS). Dados de 302 pacientes em uso de inibidores do fator de necrose tumoral (agentes anti-TNF) foram coletados por formulário padronizado. Desses, 229 (75.8%) eram mulheres e 155 (51.3%) eram brancos; a idade média foi 50,3 ± 12,8 anos, e a duração média da doença foi de 9,9 ± 8,7 anos. Entre os pacientes 214 (70,9%) usaram adalimumabe, 72 (23,8%) etanercepte e 16 (5,3%) infliximabe. A média do Health Assessment Questionnaire-Disability Index (HAQ-DI) foi 1,37 ± 0,67 para a população total. Pior resposta funcional estava associada com mulheres, pacientes casados e com um valor de EuroQoL-5 dimensions (EQ-5D) < 0.6. Correlação significativa foi obtida entre os valores de HAQ-DI, atividade das doenças e qualidade de vida. Os resultados obtidos no estudo contribuem para o melhor entendimento das características clínicas e demográficas de pacientes com doenças reumáticas iniciando a terapia com agentes anti-TNF pelo SUS. Além disso, nossos achados são consistentes com resultados obtidos em outros estudos transversais nacionais e estrangeiros. Este conhecimento pode ser de grande importância para estudos futuros que avaliem a eficácia de agentes biológicos, assim como, para contribuir para a melhoria do bem-estar das pessoas com doenças reumáticas.

Educação permanente em saúde: inventando desformações / Permanent education in health: inventing deformations

A Educação Permanente em Saúde (EPS) e sua expressão nas práticas locais é o objeto deste estudo. Buscou-se conhecer tal expressão em um município da região Médio Paraíba, interior do estado do Rio de Janeiro, considerando os movimentos institucionais e inventivos sob o referencial teórico de Paulo Freire e Adolfo Sanchez Vásquez em simbiose com a poesia de Manoel de Barros. Três questões nortearam o estudo: Quais concepções pedagógicas municipais predominam nas propostas e ações institucionais de formação? Como os trabalhadores da gestão e da atenção básica concebem e praticam a EPS no município sob as perspectivas institucional e inventiva? Como produzir, com os sujeitos participantes, dinâmicas sociais inventivas? Como metodologia de trabalho, utilizou-se a pesquisa de campo com abordagem qualitativa do tipo pesquisa ação, após aprovação pelo Comitê de Ética e Pesquisa do Hospital Universitário Antônio Pedro e autorização da secretaria de saúde do município em questão. Os dados foram coletados a partir de documentos oficiais do município, entrevistas semiestruturadas com trabalhadores da gestão e da estratégia saúde da família e observação participante em duas unidades de atenção básica. Os sujeitos participantes foram gestores/responsáveis pela condução de processos institucionais de EPS na região/município e profissionais da estratégia de saúde da família. Os documentos pesquisados foram o Plano Municipal de Saúde, período 2011-2013, a Ata da VIII Conferência Municipal de Saúde (2013) e os registros das atividades institucionais para profissionais de saúde. Observou-se que, embora os documentos relativos ao Plano Municipal de Saúde e a VIII Conferência Municipal de Saúde tenham mencionado a necessidade de formação dos profissionais de saúde, a EPS foi pouco abordada no movimento institucional, sendo a capacitação predominante. Os dados referentes às entrevistas apresentaram a EPS na perspectiva da construção de espaços formais de cursos, palestras ou reuniões. Em contrapartida, a observação participante apresentou a EPS com outro formato: sem nome, horário definido e como expressão da inventividade dos trabalhadores. A analise dos dados das entrevistas possibilitou a elaboração de duas categorias que refletem tanto a expressão da EPS no município, quanto as potencialidades e dificuldades na construção de espaços de EPS. O estudo conclui apontando para a criação de um espaço de EPS [Grupo EPensando], capaz de abarcar tanto os movimentos institucionais, como a riqueza criadora e inventiva de encontros potentes entre os trabalhadores da atenção, gestores e usuários dos serviços de saúde

The Permanent Education in Health (EPS) and its expression in local practices is the subject of this study. This research aimed to study such expression in a part of Middle Paraíba region, in State of Rio de Janeiro, taking into account the institutional and inventive movements under the theoretical framework of Paulo Freire and Adolfo Sanchez Vasquez and linked with the poetry of Manoel de Barros. Three questions guided the study: Which municipal pedagogical conceptions predominate in proposals and institutional training activities; how the workers and the management of primary health care conceive and practice the EPS in city, under the institutional and inventive perspectives; and how to produce inventive social dynamics with participating subjects. As a working methodology, we used field research with qualitative research approach and an action-type study, after the approval by the Research Ethics Committee of the Antonio Pedro University Hospital and authorization of the health department of the city in question. Data were collected from official documents of the city, semi-structured interviews with workers or managers of Family Health Strategy program and participant observation in two primary care units. Participants were managers and part of the staff in charge for conducting EPS institutional processes in the region/city and professionals from Family Health Strategy. The Municipal Health Plan from 2011 to2013, the Minutes of the Eighth Municipal Health Conference (2013) and records of institutional activities for health professionals were the documents studied. We observed that although the documents relating to the Municipal Health Plan and the 8th Municipal Health Conference have mentioned the need for training of health professionals, EPS has been little addressed in the institutional movement, being the predominant training.The data relating to interviews presented the EPS into the perspective of building formal spaces for courses, lectures or meetings; however, participant observation presented another format of EPS: with no name or time defined as an expression of workers' creativity. The analysis of the interview data allowed the creation of two categories that reflect the expression of EPS in the municipality, and the potential and difficulties in building EPS spaces. The study concludes by pointing to the creation of an area of EPS [EPensando Group] that could encompass both institutional movements as creative and inventive wealth of the powerful encounters between the health care professionals, managers and users of the services

Efetividade de programa de controle de qualidade em mamografia para o Sistema Único de Saúde / Effectiveness of a quality control program in mammography for the Brazilian National Health System / Efectividad de programa de control de calidad en mamografía para el Sistema Nacional de Salud de Brasil

OBJETIVO: Avaliar a efetividade de um programa de controle de qualidade de imagem nos serviços de mamografia da rede do Sistema Único de Saúde. MÉTODOS: Estudo prospectivo com análise temporal do tipo "antes e depois" de uma ação de vigilância em saúde. Participaram do estudo 35 serviços que tinham mamógrafos em operação e realizavam exames regularmente em Goiás entre 2007 e 2009. Foram avaliados os serviços, por testes de desempenho de mamógrafos, processadoras e demais materiais em três visitas técnicas, a qualidade da imagem e a dose de entrada no simulador radiográfico de mama. Cada serviço recebeu uma pontuação correspondente ao percentual dos testes em conformidade com os padrões. RESULTADOS: Os percentuais médios de conformidade dos serviços foram de 64,1% (± 13,3%) na primeira visita, 68,4% (± 15,9%) na segunda e 77,1% (± 13,3%) na terceira (p < 0,001). As principais melhorias foram decorrentes dos ajustes da força de compressão da mama, do controle automático de exposição e do alinhamento da bandeja de compressão. As doses medidas estavam dentro da faixa de conformidade em 80% dos serviços avaliados. CONCLUSÕES: A implantação do programa nos serviços foi efetiva para a melhoria dos parâmetros de operação do mamógrafo, embora 40% dos serviços não tenham alcançado o nível aceitável de 70%. Este resultado indica a necessidade de haver continuidade na vigilância em saúde.

OBJECTIVE: To assess the effectiveness of a quality control program in mammography services of the Brazilian National Health System (SUS). METHODS: A prospective study using temporal analysis of a health surveillance action was conducted. A total of 35 service providers that had mammography equipment in operation and regularly performed exams between 2007 and 2009 in the state of Goiás, Central-Western Brazil, participated in this study. Services were assessed during three site visits by performance testing of mammography equipment, film processors, and other materials, and image quality and entrance surface dose in a phantom were also assessed. Each service was scored according to the percentage of tests that conformed to standards. RESULTS: The mean percentage for compliance among the participating service providers were 64.1% (± 13.3%) in the first visit, 68.4% (± 15.9%) in the second, and 77.1% (± 13.3%) in the third (p < 0.001). The main improvements resulted from adjustments to the breast compression force, the automatic exposure control system, and the alignment of the compression paddle. The doses measured were within the conformity range in 80% of the services assessed. CONCLUSIONS: The implementation of this program in the mammography services was effective at improving the operational parameters of the mammography machines, although 40% of the services did not reach the acceptable level of 70%. This result indicates the need to continue this health surveillance action.

OBJETIVO: Evaluar la efectividad de un programa de control de calidad de imagen en los servicios de mamografía de la red del Sistema Único de Salud. MÉTODOS: Estudio prospectivo con análisis temporal de tipo "antes" y "después" de una acción de vigilancia en salud. Participaron del estudio 35 servicios que tenían mamógrafos operativos y que realizaban exámenes regularmente en el estado de Goiás, Brasil, entre 2007 y 2009. Se evaluaron los servicios, por pruebas de desempeño de mamógrafos , procesadoras y demás materiales en tres visitas técnicas, la calidad de la imagen y la dosis de entrada en el simulador radiográfico de mama. Cada servicio recibió una puntuación correspondiente al porcentaje de las pruebas en conformidad con los patrones. RESULTADOS: Los porcentajes promedio de conformidad de los servicios fueron de 64,1% (+/-13,3%) en la primera visita, 68,4% (+/-15,9%) en la segunda y 77,1% (+/-13,3%) en la tercera (p < 0,001). Las principales mejoras fueron decurrentes de los ajustes de la fuerza de compresión de la mama, del control automático de exposición y del alineamiento de la bandeja de compresión. Las dosis medidas estaban dentro del intervalo de conformidad en 80% de los servicios evaluados. CONCLUSIONES: La implantación del programa en los servicios fue efectiva para la mejora de los parámetros de operación del mamógrafo, a pesar de que 40% de los servicios no hayan alcanzado el nivel aceptable de 70%. Este resultado indica la necesidad de darle continuidad a la vigilancia en salud.

Planejamento estadual no SUS: o caso da Secretaria da Saúde do Estado da Bahia / Planning in Brazilian Public Health System: the case of the Health Secretariat of State of Bahia

Este artigo toma como objeto o processo de planejamento da Secretaria da Saúde do Estado da Bahia no período compreendido entre janeiro de 2007 e julho de 2009. Busca-se descrever e analisar esse processo, discutindo-se algumas dificuldades e avanços no aperfeiçoamento da prática de planejamento em saúde, por meio de uma análise de documentos desenvolvidos no período pela instituição e de registros sistemáticos dos autores sobre a experiência vivenciada. O processo se desenvolve numa tentativa de aproximar a teoria à prática, com a articulação do enfoque estratégico-situacional à perspectiva do agir comunicativo, tendo como princípio fundamental a participação social. A análise demonstra um conjunto de movimentos dialógicos, articulados por meio dos momentos explicativo, normativo, estratégico e tático-operacional, que culminam com a formulação do Plano Estadual de Saúde. Revela também a potência do planejamento diante da pluralidade e multiplicidade de abordagens utilizadas para construir coletivamente uma visão de futuro em instituições que adotam "planos" como sendo apostas à qualificação das ações de governo.

The object of this article is the planning process of the Health Secretariat of State of Bahia from January 2007 to July 2009. It describes and analyses this process, discussing the difficulties and the advances to build the planning practice in this institution. It was used documental analyses and systematic registers of lived experience by the authors to do it. The process points for an approach between theory and practice articulating the Strategic-situational focus and the Communicative Action, including the principle of the Social Participation. The analyses explain that the process occurs in a pool of dialogic movements enlaced by the explicative, normative, strategic and tactic-operative moments that finished with the construction of the Health Secretariat of State of Bahia. There is a powerful planning revealed in plurality and multiplicity of approaches used to build a collective "vision of future" in organizations that adopted "plans" like instruments to qualify Government actions.

Incertezas de pacientes no sistema público de saúde / Uncertainties of patients in the Brazilian public health system

Análises que objetivam compreender de que maneira sujeitos lidam com processos de saúde/doença geralmente dão ênfase aos modos como estes inserem suas vivências concretas em quadros avaliativos abstratos para, a partir daí, definirem ações a serem executadas. Isto posto, este artigo questiona o rendimento de tais abordagens no entendimento das experiências de pacientes do sistema público de saúde. As análises são empreendidas com base nos resultados de pesquisa realizada em instituição pública de saúde do Distrito Federal, na qual foram reconstituídos itinerários terapêuticos de seus pacientes. A pesquisa indicou que suas trajetórias são atravessadas por incertezas de diversas ordens. Tendo em vista a relevância destas e o fato de que de modo algum impedem o desenvolvimento de seus tratamentos médicos, o artigo discute como os pacientes lidam com essas incertezas e quais relações elas estabelecem com o conjunto de suas experiências. Argumenta então que suas incertezas derivam não de características imanentes a estes sujeitos, mas das relações que estabelecem com os saberes médicos e com as organizações institucionais para efetivação desses saberes, constituídas pelas instituições públicas de saúde. Mais além, demonstra que as apreciações, classificações etc. dos pacientes não se dirigem principalmente aos processos de saúde/doença em sentido estrito, mas aos mecanismos que possibilitam relações de maior sucesso com as organizações institucionais por meio das quais eles obtêm seus tratamentos.

Analyses aiming to understand how subjects deal with processes of health/disease usually emphasize the ways in which they introduce their concrete experiences into abstract evaluative frames, in order to define actions to be implemented. This being stated, this paper questions the efficiency of such approaches in understanding the experiences of the patients of Brazilian's public health system. The analyses are undertaken based on the results of research made in a public health institution of the Brazilian Federal District, in which therapeutic itineraries of its patients were reconstituted. The research indicated that their trajectories are crossed by several orders of uncertainties. Considering their relevance and the fact that in any way it impedes the promotion of their medical treatment, the paper discusses how patients deal with these uncertainties and which relationships are established with the ensemble of their experiences. It is then argued that their uncertainties do not come from the inherent characteristics of the patients but from the relations they establish with (1) the medical knowledge and (2) the institutional organizations in which this knowledge is accomplished by the public health institutions. Further it shows that the patients' assessments, classifications etc. are not mainly directed to the processes of health/disease in the strict sense, but to the mechanisms that allow more successful relationships with the institutional organizations through which they receive their treatment.