Integrated care improves mental health in a medically underserved U.S.-Mexico border population.

INTRODUCTION: Chronic conditions, particularly diabetes, and related health conditions continue to be a major concern in the United States, especially in Hispanic populations. This study evaluated the effect of an integrated behavioral health care model, including promotoras(es), on a primarily Hispanic population living with diabetes. METHOD: Seven hundred fifty-six participants were enrolled in an intervention (n = 329) or comparison group (n = 427) and followed up for 12 months. We used a quasiexperimental design to compare participants who received coordinated integrated behavioral health care with those who received usual care from a federally qualified health center. The outcomes were HbA1c, blood pressure, body mass index, depressive symptoms (Patient Health Questionnaire-9), and quality of life (QoL). These outcomes were analyzed as continuous variables using linear regression with backward model selection. Longitudinal analyses were conducted using a likelihood-based approach to general linear mixed models. RESULTS: A total 563 intervention (n = 239) and comparison (n = 324) participants completed an end point assessment. After adjusting for important covariates, the intervention had a QoL score 5.36 points higher than the comparison participants on average after 12 months. The trajectories of QoL and Patient Health Questionnaire-9 scores differed over time, with intervention participants experiencing greater improvements. There were no statistically significant differences detected for other outcomes. DISCUSSION: Enabling access to services and providers to enhance participants' ability to manage their chronic disease led to positive impacts on mental health. The connection between QoL and diabetes has been of great interest to researchers, including the effects of relationships with promotoras(es). The impact of integrating care on QoL in this vulnerable population is discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Promoting Integrated Mental Health Care Services in Disaster Response Programs: Lessons Learned After the Impact of Hurricane María in Puerto Rico.

Meteorological and even human-made disasters are increasing every year in frequency and magnitude. The passage of a disaster affects a society without distinction, but groups with social vulnerability (low socioeconomic status, chronic medical, or psychological conditions, limited access to resources) face the most significant impact. As a result, psychological and behavioral symptoms (eg, depression and anxiety) can ensue, making the immediate response of mental health services crucial. Secondary data from a database of a temporary healthcare unit were analyzed. A total of 54 records were reviewed to collect information; univariate and bivariate analyses were done. The purpose of this article is to present our experience regarding the incorporation of a mental health services model, with its respective benefits and challenges, into a temporary healthcare unit, after Hurricane Maria in 2017.

Contrasting current challenges from the Brazilian and Canadian national health systems: The Besrour Papers: a series on the state of family medicine in Canada and Brazil.

OBJECTIVE: To compare the national health systems of Canada and Brazil and how both countries have addressed similar challenges in their primary care sectors. COMPOSITION OF THE COMMITTEE: A subgroup of the Besrour Centre of the College of Family Physicians of Canada developed connections with colleagues in Brazil and collaborated to undertake a between-country comparison, comparing and contrasting various elements of both countries' efforts to strengthen primary care over the past few decades. METHODS: Following a literature review, the authors collectively reflected on their experiences in an attempt to explore the past and current state of family medicine in Canada and Brazil. REPORT: The Brazilian and Canadian primary care systems are faced with similar challenges, including geography, demographic changes, population health inequities, and gaps in universal access to comprehensive primary care services. Although the approaches to addressing these challenges are different in both settings, they highlight the central importance of family physicians in both systems. Both countries continue to face considerable challenges in the context of mental health services in primary care. It remains important for Canada to draw lessons from the primary care systems and reforms of other countries, such as Brazil.

Inclusion of mental health in primary health care: care strategy in the territory / Inclusión de la salud mental en la atención primaria de salud: una estrategia de cuidado en el territorio / Inclusão da saúde mental na atenção básica à saúde: estratégia de cuidado no território

ABSTRACT Objective: To analyze the strategies, challenges and possibilities of the articulation between mental health and primary health care from the perspective of health managers. Method: Exploratory, qualitative research carried out with 28 managers of mental health and primary care. The data were collected through semi-structured interviews between July and November 2013 and submitted to thematic content analysis. Results: The inclusion of mental health actions in primary care made it possible, in the view of managers, to increase users' access to the care they need. This care strategy allows the extension of care practices in the territory, with matrix support as the main tool for the implementation of this care strategy. Final considerations: The articulation between primary care and mental health is a powerful device for psychosocial care, but it demands a new conformation of the Psychosocial Care Centers (Caps) and primary care services.

RESUMEN Objetivo: analizar las estrategias, los desafíos y las posibilidades de articulación entre la salud mental y la atención primaria de salud desde la perspectiva de los gestores de la salud. Método: investigación exploratoria y cualitativa, realizada con 28 gestores de salud mental y de la atención primaria. En la recopilación de datos se utilizaron entrevistas semiestructuradas, realizadas en el período entre julio y noviembre de 2013, las cuales se sometieron al análisis de contenido temático. Resultados: desde la perspectiva de los gestores, la inclusión de las acciones de salud mental en la atención primaria permitió que los usuarios amplíen el acceso al cuidado que necesitan. Esta estrategia de atención permite difundir las prácticas de cuidado en el territorio, y cuenta con un apoyo central como la principal herramienta para implementar esta estrategia de cuidado. Consideraciones finales: la articulación entre la atención primaria y la salud mental es un mecanismo clave en la atención psicosocial, sin embargo, demanda una nueva conformación de los Centros de Atención Psicosocial (Caps) y de los servicios de la atención básica.

RESUMO Objetivo: analisar as estratégias, desafios e possibilidades da articulação entre a saúde mental e a atenção básica à saúde a partir da perspectiva de gestores da saúde. Método: pesquisa exploratória, qualitativa, realizada com 28 gestores de saúde mental e atenção básica. Os dados foram coletados por meio de entrevistas semiestruturadas, entre julho e novembro de 2013, e submetidos à análise de conteúdo temática. Resultados: a inclusão das ações de saúde mental na atenção básica possibilitou, na visão dos gestores, a ampliação do acesso dos usuários aos cuidados de que necessitam. Esta estratégia de atenção possibilita extensão das práticas de cuidado no território, tendo o apoio matricial como a principal ferramenta para a implementação dessa estratégia de cuidado. Considerações finais: a articulação entre a atenção básica e a saúde mental é um dispositivo potente para a atenção psicossocial, porém, demanda uma nova conformação dos Centros de Atenção Psicossocial (Caps) e dos serviços da atenção básica.

Inclusion of mental health in primary health care: care strategy in the territory.

OBJECTIVE: To analyze the strategies, challenges and possibilities of the articulation between mental health and primary health care from the perspective of health managers. METHOD: Exploratory, qualitative research carried out with 28 managers of mental health and primary care. The data were collected through semi-structured interviews between July and November 2013 and submitted to thematic content analysis. RESULTS: The inclusion of mental health actions in primary care made it possible, in the view of managers, to increase users' access to the care they need. This care strategy allows the extension of care practices in the territory, with matrix support as the main tool for the implementation of this care strategy. FINAL CONSIDERATIONS: The articulation between primary care and mental health is a powerful device for psychosocial care, but it demands a new conformation of the Psychosocial Care Centers (Caps) and primary care services.

Epidemic of Chronic Kidney Disease of Nontraditional Etiology in El Salvador: Integrated Health Sector Action and South-South Cooperation.

In El Salvador, chronic kidney disease had reached epidemic propor-tions towards the end of this century's first decade. In 2011-2012, the Ministry of Health reported it was the leading cause of hospital deaths in men, the fifth in women, and the third overall in adult hospital fa-talities. Farming was the most common occupation among men in dialysis (50.7%). By 2017, chronic kidney disease admissions had overwhelmed hospital capacity.In 2009, El Salvador's Ministry of Health, Cuba's Ministry of Public Health and PAHO launched a cooperative effort to comprehensively tackle the epidemic. The joint investigations revealed a total prevalence of chronic kidney disease in the adult population of farming communities higher than that reported internationally (18% vs.11%-14.8%), higher in men than in women (23.9% vs 13.9%) and higher in men who were farmers/farmworkers than in men who were not (31.3% vs. 14.8%). The disease was also detected in children. An association was found between chronic kidney disease and exposure to agrochemicals (OR 1.4-2.5). In 51.9% of all chronic kidney disease cases, traditional causes (diabetes, hyperten-sion, glomerulopathies, obstructive nephropathies and cystic diseases) were ruled out and the existence of a particular form of chronic kidney disease of nontraditional etiology was confirmed (whose initial cases were reported as early as 2002). In the patients studied, functional altera-tions and histopathologic diagnosis confirmed a chronic tubulointerstitial nephritis; most presented with neurosensory hearing loss, altered tendon refiexes and tibial artery damage. The main results of this cooperation were the epidemiologic, physio-pathologic, clinical and histopathologic characterization of chronic kid-ney disease of nontraditional etiology. This characterization facilitated case definition for the epidemic and led to the hypothesis of systemic toxicity from agrochemicals (e.g., paraquat, glyphosate), which par-ticularly affect the kidneys and to which farmers/farmworkers (who may also become dehydrated in the fields) are most exposed. The research thus also laid the foundations for design of comprehensive intersectoral government actions to reduce cases and put an end to the epidemic. KEYWORDS Chronic kidney disease; chronic renal failure; tubuloint-erstitial nephritis; epidemiology; histopathology; international coopera-tion; agrochemicals; environmental pollutants, noxae, and pesticides; occupational health; PAHO; El Salvador; Cuba.

Mental health as a dimension for the care of teenagers.

OBJECTIVE: To analyze the demands in the field of mental health from the perspective of teenagers. METHOD: A descriptive study with a qualitative approach, having comprehensiveness as an analytical category. It was carried out with 21 teenagers of both genders, students of two public schools of a municipality of the countryside of Bahia state. The empirical material was produced through reflection workshops and analyzed through the technique of Discourse Analysis. RESULTS: Teenagers value the indissociability between body and mind, recognize lack of attention to the psychological dimension in the health network, and point to mental disorders as resulting from contexts of life and lack of Health Care. CONCLUSION: Health services need to be structured to attract teenagers, to recognize singularities through professionals trained in welcoming, listening and accountability. It is urgent to fulfill what is defined in public policies and in specific programs, and that comprehensiveness has a centrality as a perspective to be realized.

Mental health as a dimension for the care of teenagers / La salud mental como dimensión para el cuidado de adolescentes / Saúde mental como dimensão para o cuidado de adolescentes

ABSTRACT Objective: To analyze the demands in the field of mental health from the perspective of teenagers. Method: A descriptive study with a qualitative approach, having comprehensiveness as an analytical category. It was carried out with 21 teenagers of both genders, students of two public schools of a municipality of the countryside of Bahia state. The empirical material was produced through reflection workshops and analyzed through the technique of Discourse Analysis. Results: Teenagers value the indissociability between body and mind, recognize lack of attention to the psychological dimension in the health network, and point to mental disorders as resulting from contexts of life and lack of Health Care. Conclusion: Health services need to be structured to attract teenagers, to recognize singularities through professionals trained in welcoming, listening and accountability. It is urgent to fulfill what is defined in public policies and in specific programs, and that comprehensiveness has a centrality as a perspective to be realized.

RESUMEN Objetivo: Analizar las demandas en el ámbito de la salud mental según la perspectiva de los adolescentes. Método: Estudio descriptivo, con abordaje cualitativo, teniendo integralidad como categoría analítica. Realizado con 21 adolescentes de ambos sexos, estudiantes de dos escuelas públicas de un municipio del interior bahiano. El material empírico fue producido por medio de talleres de reflexión y analizado por medio de la técnica del análisis de discurso. Resultados: Los adolescentes valoran la directa asociación entre cuerpo y mente, reconocen carencia de atención a la dimensión psicológica en la red de salud y apuntan trastornos psíquicos como resultado de contextos de vida y de falta de atención a la salud. Conclusión: Los servicios de salud necesitan estructurarse para atraer a los adolescentes, reconocer singularidades a través de profesionales capacitados para la acogida, la escucha y la rendición de cuentas. Es urgente cumplir lo que está definido en políticas públicas y en programas específicos y garantizar que la integralidad tenga centralidad como perspectiva a concretarse.

RESUMO Objetivo: Analisar demandas no âmbito da saúde mental na perspectiva de adolescentes. Método: Estudo descritivo, com abordagem qualitativa, tendo integralidade como categoria analítica. Foi realizado com 21 adolescentes de ambos os sexos, estudantes de duas escolas públicas de um município do interior baiano. O material empírico foi produzido por meio de oficinas de reflexão e analisado por meio da técnica de Análise de Discurso. Resultados: Adolescentes valorizam a indissociabilidade entre corpo e mente, reconhecem carência de atenção à dimensão psicológica na rede de saúde, e apontam transtornos psíquicos como resultantes de contextos de vida e de falta de Atenção à Saúde. Conclusão: Os serviços de saúde necessitam estruturar-se para atrair adolescentes, reconhecer singularidades por meio de profissionais capacitadas/os para o acolhimento, a escuta e a responsabilização. Urge cumprir o que está definido em políticas públicas e em programas específicos, e que a integralidade tenha centralidade como perspectiva a se concretizar.

Medication therapy disease management: Geisinger's approach to population health management.

PURPOSE: Pharmacists' involvement in a population health initiative focused on chronic disease management is described. SUMMARY: Geisinger Health System has cultivated a culture of innovation in population health management, as highlighted by its ambulatory care pharmacy program, the Medication Therapy Disease Management (MTDM) program. Initiated in 1996, the MTDM program leverages pharmacists' pharmacotherapy expertise to optimize care and improve outcomes. MTDM program pharmacists are trained and credentialed to manage over 16 conditions, including atrial fibrillation (AF) and multiple sclerosis (MS). Over a 15-year period, Geisinger Health Plan (GHP)-insured patients with AF whose warfarin therapy was managed by the MTDM program had, on average, 18% fewer emergency department (ED) visits and 18% fewer hospitalizations per year than GHP enrollees with AF who did not receive MTDM services, with 23% lower annual total care costs. Over a 2-year period, GHP-insured patients with MS whose pharmacotherapy was managed by pharmacists averaged 28% fewer annual ED visits than non-pharmacist-managed patients; however, the mean annual total care cost was 21% higher among MTDM clinic patients. CONCLUSION: The Geisinger MTDM program has evolved over 20 years from a single pharmacist-run anticoagulation clinic into a large program focused on managing the health of an ever-growing population. Initial challenges in integrating pharmacists into the Geisinger patient care framework as clinical experts were overcome by demonstrating the MTDM program's positive impact on patient outcomes.

Variation in Management of Patients With Obstructive Coronary Artery Disease: Insights From the Veterans Affairs Clinical Assessment and Reporting Tool (VA CART) Program.

BACKGROUND: Little is known about facility-level variation in the use of revascularization procedures for the management of stable obstructive coronary artery disease. Furthermore, it is unknown if variation in the use of coronary revascularization is associated with use of other cardiovascular procedures. METHODS AND RESULTS: We evaluated all elective coronary angiograms performed in the Veterans Affairs system between September 1, 2007, and December 31, 2011, using the Clinical Assessment and Reporting Tool and identified patients with obstructive coronary artery disease. Patients were considered managed with revascularization if they received percutaneous coronary intervention (PCI) or coronary artery bypass grafting within 30 days of diagnosis. We calculated risk-adjusted facility-level rates of overall revascularization, PCI, and coronary artery bypass grafting. In addition, we determined the association between facility-level rates of revascularization and post-PCI stress testing. Among 15 650 patients at 51 Veterans Affairs sites who met inclusion criteria, the median rate of revascularization was 59.6% (interquartile range, 55.7%-66.7%). Across all facilities, risk-adjusted rates of overall revascularization varied from 41.5% to 88.1%, rate of PCI varied from 23.2% to 80.6%, and rate of coronary artery bypass graftingvariedfrom 7.5% to 36.5%. Of 6179 patients who underwent elective PCI, the median rate of stress testing in the 2 years after PCI was 33.7% (interquartile range, 30.7%-47.1%). There was no evidence of correlation between facility-level rate of revascularization and follow-up stress testing. CONCLUSIONS: Within the Veterans Affairs system, we observed large facility-level variation in rates of revascularization for obstructive coronary artery disease, with variation driven primarily by PCI. There was no association between facility-level use of revascularization and follow-up stress testing, suggesting use rates are specific to a particular procedure and not a marker of overall facility-level use.

Developing family practice to respond to global health challenges: The Besrour Papers: a series on the state of family medicine in the world.

OBJECTIVE: To assess family medicine's role in developing strong, coordinated, community-based, integrated health care systems in low-resource settings globally. COMPOSITION OF THE COMMITTEE: A subgroup of the Besrour Centre of the College of Family Physicians of Canada developed connections with selected international colleagues with expertise in international family medicine practice, health systems and capacity building, and teaching to map family medicine globally and give a bird's eye view of family medicine internationally. METHODS: Following a background literature review, the authors collectively reflected on their substantial international experience to attempt to describe best practices for various contexts. REPORT: With the failure of vertical, disease-oriented models to provide sustained improvements in health outcomes, the need to develop integrated primary care involving the most appropriate health professionals for differing contexts is becoming apparent worldwide. Health system planning is required to develop policies on health professional training to achieve this. Advocating and offering appropriate incentives for, and coordination of, local opportunities within the health system also becomes paramount. The adaptability and generalist nature of family medicine allows it to respond to the unique needs of a given population. Family physicians with adequate financial and physical resources can function most effectively as members of interdisciplinary teams, thus providing valuable, comprehensive health services in any area of the world.

Are Kidney Transplant Patients Receiving Chronic Kidney Disease Treatment? A Comparative Study to Predialysis Patients in a Multidisciplinary Setting.

OBJECTIVES: Kidney transplant recipients present with treatable complications related to chronic kidney disease, similarly to predialysis patients. The role of multidisciplinary clinics in the management of these complications in kidney transplant recipients is not fully understood. The objective of the present study was to compare the availability of specific treatments for chronic kidney disease-related complications between predialysis patients and kidney transplant recipients, both followed by a multidisciplinary team. MATERIALS AND METHODS: In a cross-sectional study, we compared the prevalence of chronic kidney disease-related complications and the presence or absence of treatment for those complications, when clinically indicated, in 133 kidney transplant recipients and 114 predialysis patients, all followed by a multidisciplinary team of nephrologists, nurses, dieticians, social workers, and psychologists. RESULTS: Kidney transplant recipients were younger, had better kidney function, and lower prevalence of hypertension, proteinuria, diabetes, obesity, cardiovascular disease, anemia, hyperuricemia, hypocalcemia, and hyperphosphatemia. However, the availability of treatment for anemia (odds ratio of 0.58; 95% confidence interval, 0.2-1.6; P = .31), dyslipidemia (odds ratio of 0.9; 95% confidence interval, 0.3-2.4; P = .84), metabolic acidosis (odds ratio of 3.75; 95% confidence interval, 0.8-18.2; P = .101), hyperphosphatemia (odds ratio of 1.89; 95% confidence interval, 0.3-10.8; P = .47), and hyperuricemia (odds ratio of 1.3; 95% confidence interval, 0.3-6.2; P = .73) was similar between the groups. CONCLUSIONS: Despite clinical and demographic differences, the comparable treatment directed to chronic kidney disease-related complications for both predialysis patients and kidney transplant recipients suggests that a multidisciplinary approach could be appropriate for better clinical management of chronic kidney disease in kidney transplant recipients.

Clinical oncology practice 2015: preparing for the future.

The clinical practice of oncology has become increasingly complex. An explosion of medical knowledge, increased demands on provider time, and involved patients have changed the way many oncologists practice. What was an acceptable practice model in the past may now be relatively inefficient. This review covers three areas that address these changes. The American Society of Clinical Oncology (ASCO) National Oncology Census defines who the U.S. oncology community is, and their perceptions of how practice patterns may be changing. The National Cancer Institute (NCI)-ASCO Teams in Cancer Care Project explores how best to employ team science to improve the efficiency and quality of cancer care in the United States. Finally, how physician assistants (PAs) and nurse practitioners (NPs) might be best integrated into team-based care in oncology and the barriers to integration are reviewed.

Vivências em serviço de urgências: o papel dos acompanhantes dos doentes / Emergency room: the role of the accompanying person

As pessoas que acompanham um utente no serviço de urgência (SU), familiares ou não, são parte integrante da unidade de cuidados. Em Portugal, a prática comum no acompanhamento a adultos é a permanência numa sala de espera exterior. Este estudo exploratório realizado em Portugal procura compreender melhor as vivências em SU dos diversos envolvidos, procurando clarificar o papel dos acompanhantes no serviço de urgência, para reflectir sobre formas de promover a sua participação em todo o processo. Adoptou-se a técnica dos incidentes críticos que foi aplicada por entrevista a 71 indivíduos que representam as diversas partes envolvidas: 2 administrativos (2,8 por cento); 7 médicos (9,9 por cento); 9 auxiliares de acção médica (12,7 por cento); 9 bombeiros (12,7 por cento); 9 utentes (12,7 por cento); 20 enfermeiros (28,2 por cento); 15 acompanhantes (21,1 por cento). Os principais resultados indicam que: i) os participantes relatam mais incidentes negativos que positivos (72,9 por cento), associados a comportamentos e atitudes emocionais (tais como, agressividade dos acompanhantes, distância e agressividade dos profissionais e acompanhantes que dificultam a prestação de cuidados); ii) os participantes raramente referem insatisfação ou ineficácia dos cuidados e tratamentos (constituem 4,3 por cento dos incidentes); ii) os incidentes positivos (17,1 por cento) referem-se a profissionais humanos e sensíveis (50 por cento) e eficazes (25 por cento). O serviço de urgência constitui uma zona de tempestade emocional e é necessário repensar a forma como o acompanhante dos doentes decorre.

Those who accompany a patient in the emergency service, either members of the family or others, are an integral part of the care unit. In Portugal, the usual practice in adults' accompaniment is the permanence in an exterior waiting room. This exploratory study aims at better understanding the emergency service experiences of all those involved, trying to clarify the role of the accompanying person, and reflecting on ways of promoting their participation in the entire process. The Critical Incidents Technique was adopted and administered by interview to 71 participants that represent the several involved parts: 2 administrative workers (2.8%); 7 doctors (9.9%); 9 medical assistants (12.7%); 9 fire-fighters (12.7%); 9 users (12.7%); 20 nurses (28.2%); 15 accompanying persons (21.1%). The main results suggest that: i) participants report more negative incidents (72.9%), related to emotional behaviours and attitudes (such as accompanying person's aggressiveness, professionals' distance and aggressiveness); ii) participants' reference to dissatisfaction or inefficacy of care is rare (4.3% of the incidents); iii) positive incidents are centred on sensitive professionals (50%) and efficacy (25%). The emergency service is an area of emotional storm and it is necessary to rethink the way users are being accompanied by their dear ones.

Chronic kidney disease in Cuba: epidemiological studies, integral medical care, and strategies for prevention.

The experience of the Republic of Cuba regarding epidemiological studies, integral medical care, and strategies for the prevention of chronic kidney disease is summarized in this report. Cuba has a National Program for Chronic Renal Disease, Dialysis, and Renal Transplantation. There is a national nephrology net, integrated by the Institute of Nephrology as the coordinator center, that has 47 nephrology services with a hemodialysis unit (24 of them with peritoneal dialysis unit), 9 transplantation centers, 33 organ procurement hospitals, and 5 histocompatibility laboratories. In 2004, the incidence rate in dialysis patients was 111 pmp, and the prevalence rate was 149 pmp, demonstrating an increasing mean of 17.0% and 10.0% per year, respectively. Renal transplantation rate was 16.6 pmp. The detection, registration, and follow-up of patients with chronic kidney disease (serum creatinine > or =1.5 mg/dL or glomerular filtration rate <60 mL/min) by family doctors was 9,761 patients, 0.87 patients per 1,000 inhabitants. In the 1980s, three population-based screening studies were performed to define the burden of chronic renal failure in different regions of Cuba. The prevalence rate was 1.1, 3.3, and 3.5 per 1,000 inhabitants, respectively. At present, another three population-based screening studies are ongoing in order to detect the chronic kidney disease in earliest stages. The continuing medical education activities have been very useful in raising the awareness of medical doctors and the basic health staff about the threats posed by and the strategies to prevent, diagnose, and treat chronic kidney disease.

Public health policies as guides for local public policies: the experience of Sobral-Ceará, Brazil.

The accelerated urbanisation process that Brazil has gone through in the last 50 years has given rise to daunting challenges for public managers, especially in terms of local public policy management for the building of "healthy cities". In Sobral, a municipality of 173,000 inhabitants in Ceará in the North-eastern region of Brazil, a number of municipal policies were initiated beginning in 1997, many in partnership with the federal and state governments. They were inspired by the vision of a healthy and equitable city and were marked by strategic planning and the implementation of intersectoral projects. This article lays out some of the actions and their results, including an increase in the public supply of drinking water from 65% to 97% of households; an increase in sewage networks from 7% to 65%; an increase in public refuse collection from 42% to 90%; the expansion of green areas; the construction of nine kilometres of bicycle paths; the universalisation of integral health care through the Family Health Strategy through a network with specialised out-patient and hospital services; and a 148% increase in the number of children enrolled in primary school. These initiatives also resulted in the improvement of quality of life indicators, including a reduction in infant mortality from 61.4 to 19.0 per thousand live births, a drop in the mortality rate from traffic accidents from 33.40 per 100,000 inhabitants in 2001 to 15.25 in 2003; and a jump in literacy rates among children in the first cycle of primary school from 40 to 90.7%. In the present article, the authors describe some of the successful strategies and projects initiated between 1997 and 2003, and discuss how this experience could be reproduced in other communities across Brazil and around the world.

Aqui se paga, aqui se faz: pagamento a provedores como instrumento de política: contribuição à discussão do caso da terapia renal substitutiva / Here you pay here is done: payment providers such as policy instrument: contribution to the discussion of the case of renal replacement therapy

Este estudo tem por objetivo contribuir para a formulação de políticas na área da terapia renal substitutiva na perspectiva da construção de um modelo de atenção integral ao paciente renal crônico. Tomou-se como ponto de partida a necessidade de desenvolver instrumentos que operacionalizem as políticas, entre os quais os métodos de pagamento são estratégicos. Para tal, foi desenvolvido o estudo comparativo das características da provisão de diálise em 14 países de renda alta, procurando compreender de que forma o tipo de sistema de saúde, o mix público privado adotado na provisão de serviços e os mecanismos de pagamento a provedores contribuíram para as diferenças que se observam nas taxas de pacientes em tratamento, de pacientes aceitos em programa a cada ano, na escolha da modalidade de terapia e na mortalidade em diálise. A análise é aprofundada para os casos americano e britânico, que representam duas configurações polares de oferta e utilização da terapia. Discutem-se ainda as recentes experiências americanas de substituição do pagamento por procedimentos pelo pagamento por capitação, seus primeiros resultados e desdobramentos. A análise dos casos mostrou que os métodos de pagamento sempre foram um elemento essencial da política de atenção ao paciente renal crônico e que articulados à análise do mix público-privado em cada caso, explicam boa parte das diferenças observadas entre os países. São portanto, um poderoso instrumento a ser utilizado pelo gestor público, especialmente em sistemas onde é muito importante o peso da provisão privada, como é o nosso caso...

Integrative medicine: a paradigm shift in medical education and practice

The use of alternative/complementary medicine has been increasing considerably. Conventional medicine must begin to address issues related to the use, safety, regulation, research and education of alternative/complementary medicine. Integrative medicine combines conventional medicine and alternative complementary practices. Integrative medicine is an innovative approach to medicine and medical education. It involves the understanding of the interaction of the mind, body and spirit and how to interpret this relationship in the dynamics of health and disease. Integrative medicine shifts the orientation of the medical practice from disease based approach to a healing based approach. It does not reject conventional medicine nor uncritically accepts unconventional practices. Integrative medicine is an effective, more fulfilling human approach to medicine based on the benefit of the patient by following good medicine practices in a scientific manner.

Integrative medicine: a paradigm shift in medical education and practice.

The use of alternative/complementary medicine has been increasing considerably. Conventional medicine must begin to address issues related to the use, safety, regulation, research and education of alternative/complementary medicine. Integrative medicine combines conventional medicine and alternative complementary practices. Integrative medicine is an innovative approach to medicine and medical education. It involves the understanding of the interaction of the mind, body and spirit and how to interpret this relationship in the dynamics of health and disease. Integrative medicine shifts the orientation of the medical practice from disease based approach to a healing based approach. It does not reject conventional medicine nor uncritically accepts unconventional practices. Integrative medicine is an effective, more fulfilling human approach to medicine based on the benefit of the patient by following good medicine practices in a scientific manner.