Pessoas Transexuais e Travestis em uma unidade de referência da Secretaria de Saúde do Rio de Janeiro: Estratégia em saúde para facilitação do acesso no atendimento / Transsexuals and Transvestites in a reference unit of the Health Department of Rio de Janeiro: Health strategy to facilitate access to care

O objetivo geral deste estudo foi conhecer as narrativas de vida das pessoas transexuais e travestis assistidas no Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), com ênfase no acesso à saúde para acompanhamento hormonal na unidade de referência estadual. Como método, foi utilizada a pesquisa qualitativa e descritiva, que consistiu em duas etapas: as entrevistas, de uma forma particular, que se deram através das narrativas de vida de Daniel Bertaux e a caracterização do perfil sociodemográfico das pessoas transexuais e travestis atendidas pelo Serviço Social no Ambulatório Multidisciplinar de Identidade de Gênero (AMIG). Foram entrevistadas 16 pessoas, dentre elas: 6 mulheres transexuais, 2 travestis e 8 homens transexuais, mediante a assinatura do Termo de Consentimento Livre e Esclarecido. Para a caracterização do perfil foram coletados os dados dos prontuários de 458 pessoas. Nos resultados e discussão, identificou-se a dificuldade no acesso associados à falta de qualificação dos profissionais de saúde para o acolhimento e regulação, a falta de um protocolo padronizado para regulação, a rotatividade dos profissionais da atenção primária de saúde, e a centralização do atendimento realizado pela unidade de referência.

Intervention model for detection, prevention and control of COVID-19 in community pharmacy

Abstract The announcement by the WHO of the characterization of the new Coronavirus 2019 disease (COVID-19) as a pandemic, entails an adaptation by the community pharmacy in carrying out its care activity in general, with particular emphasis on "Minor Ailments Service" in particular. The measures taken by the different health administrations in which patient telephone care by primary care offices is prioritized have left more consultations on symptoms in the community pharmacist health-related problems as pharmacies are the closest health facilities to the patient. The similarity between the symptomatology caused by the new Coronavirus with that of some Enteroviruses that cause mild respiratory and gastrointestinal tables (dry cough, fever, sore throat, vomiting, diarrhoea, etc.) makes community pharmacies highly capable places for contagion detection and prevention. A model of protocolized intervention is needed to facilitate the pharmacist's work in discriminating during the indication between minor symptoms and symptoms of referral for possible cases of COVID-19 so that in conjunction with the rest of the staff we help control the disease and make better use of primary care consultations.

Pharmaceutical services in primary health care: dissatisfaction among users, managers and pharmacists

Abstract To assess the performance indicators for pharmaceutical services (PS) in primary health care (PHC), the level of satisfaction with pharmacy services among users and managers / pharmacists' impressions in relation to the findings were evaluated. The study used mixed methods, including a retrospective and descriptive study of the performance indicators for PS in PHC, an observational study on the level of satisfaction and a qualitative study of users' perception of pharmacy services at Health Units. Managers and pharmacists' impressions of the study results were also collected. Only 44.4% of pharmacies had a full-time pharmacist. From the establishments visited, 5.3% did not have an air-conditioned environment, and only 33.3% of the items essential to the Good Practices of Storage of Medicines and Supplies criteria were fulfilled. Although 77.9% of the prescribed medicines were dispensed, it did not reach the 80% standard. The satisfaction level of users was 3.2±0.6, indicating dissatisfaction with pharmacies' services. By means of an evaluation of each item within the questionnaire, it was possible to observe that variables related to pharmaceutical care presented low scores in relation to other domains, thus evidencing the fragility of the pharmaceutical- patient relationship in users' perception. Managers and pharmacists suggested that these results were related to the inadequate physical infrastructure of pharmacies, work overload, lack of recognition and undervaluation of pharmacists, lack of interaction within the PHC team, high turnover of pharmacists, and lack of PS prioritization by the administration. PS in PHC has structural and organizational weaknesses that require changes. In general, users are dissatisfied with pharmacies' services, especially with pharmaceutical care.

Glycemic control and associated factors in patients with type 1 diabetes mellitus in primary care in Southeastern Brazil

Abstract Diabetes is a self-managed condition with knowledge, attitudes and practices that can influence the overall treatment and outcomes delay the complications of diabetes. However, the few reported studies published point out that: low education level, poor adherence to pharmacotherapy and diet recommendations, infrequent monitoring of blood glucose, and insulin dosage regimen are associated with higher hemoglobin levels. This study aimed to assess the knowledge, adherence medication, and complexity of pharmacotherapy in T1DM patients in Brazil. A cross-sectional study was conducted involving 156 T1DM patients who were attending in primary care. Logistic regression analyses were conducted to assess the variables associated with glycemic control. The overall assessments of T1DM patients for the glycemic control were bad (121, 77.6%). However, T1DM patients with high MedTake Test (OR=2.4, CI=1.1-5.7) and Morisky-Green Test (OR= 2.5, CI=1.1-6.1), and in the use of dosage insulin (>40 units, OR=0.3, CI=0.1-0.7) and postprandial glucose (100-125mg/dl, OR=3.8, CI=1.1-14.6) had better glycemic control compared to uncontrolled patients. Glycemic control in Brazilians adults with T1DM is low. We suggested the screening patients with low MedTake and Morisky-Green Tests, increasing patient knowledge as part of a complex intervention that may lead to substantially improved treatment outcomes in primary care

How to Identify Team-based Primary Care in the United States Using Medicare Data.

BACKGROUND: Studying team-based primary care using 100% national outpatient Medicare data is not feasible, due to limitations in the availability of this dataset to researchers. METHODS: We assessed whether analyses using different sets of Medicare data can produce results similar to those from analyses using 100% data from an entire state, in identifying primary care teams through social network analysis. First, we used data from 100% Medicare beneficiaries, restricted to those within a primary care services area (PCSA), to identify primary care teams. Second, we used data from a 20% sample of Medicare beneficiaries and defined shared care by 2 providers using 2 different cutoffs for the minimum required number of shared patients, to identify primary care teams. RESULTS: The team practices identified with social network analysis using the 20% sample and a cutoff of 6 patients shared between 2 primary care providers had good agreement with team practices identified using statewide data (F measure: 90.9%). Use of 100% data within a small area geographic boundary, such as PCSAs, had an F measure of 83.4%. The percent of practices identified from these datasets that coincided with practices identified from statewide data were 86% versus 100%, respectively. CONCLUSIONS: Depending on specific study purposes, researchers could use either 100% data from Medicare beneficiaries in randomly selected PCSAs, or data from a 20% national sample of Medicare beneficiaries to study team-based primary care in the United States.

Primary Health Care attributes in the context of indigenous health.

OBJECTIVES: to assess the attributes of Primary Health Care from the perspective of health professionals, comparing services in the Special Indigenous Health District and the Municipal Health Offices. METHODS: a cross-sectional study in the Upper Rio Negro region, State of Amazonas, with 116 professionals. The data were collected through the Primary Care Assessment Tool. Scores were categorized (≥ 6.6) - strong orientation and (<6.6) - low orientation. The chi-square and maximum likelihood test for crossover analysis. The comparison between professionals the Kruskal-Wallis Test. RESULTS: a higher overall score was observed in the Indigenous Health District (7.2). The same trend was observed individually in the essential and derived attributes. CONCLUSIONS: this work may support strategies that positively impact the management model and work processes from the perspective of strengthening the primary care offered to the population from Rio Negro.

Integrating Community and Clinical Data to Assess Patient Risks with A Population Health Assessment Engine (PHATE).

Clinicians are concerned about their patients' social determinants of health (SDH); yet, they are unsure how to effectively gather patient-level SDH data and intervene without adding to current administrative burdens. Designed properly, clinical registries offer solutions to integrate neighborhood SDH data with clinical data from electronic health records, enabling the understanding of community factors to guide patient care. Federal and state interest in adjusting reimbursements based on SDH further underscores the need for strategies that integrate SDH and clinical data. The Population Health Assessment Engine (PHATE) exemplifies a registry-based SDH data integration solution that adjusts payments, contributes to public health surveillance, organizes care around hot spots (gaps in quality or uncontrolled disease), assesses patient risk, and connects with community organizations. PHATE also permits residency training to meet community health competency milestones by incorporating the PHATE curriculum. These functions enhance value, and their utility in education and care delivery would benefit from further investigation.

Primary Health Care attributes in the context of indigenous health / Atributos de la Atención Primaria de Salud en el contexto de la salud indígena / Atributos da Atenção Primária à Saúde no contexto da saúde indígena

ABSTRACT Objectives: to assess the attributes of Primary Health Care from the perspective of health professionals, comparing services in the Special Indigenous Health District and the Municipal Health Offices. Methods: a cross-sectional study in the Upper Rio Negro region, State of Amazonas, with 116 professionals. The data were collected through the Primary Care Assessment Tool. Scores were categorized (≥ 6.6) - strong orientation and (<6.6) - low orientation. The chi-square and maximum likelihood test for crossover analysis. The comparison between professionals the Kruskal-Wallis Test. Results: a higher overall score was observed in the Indigenous Health District (7.2). The same trend was observed individually in the essential and derived attributes. Conclusions: this work may support strategies that positively impact the management model and work processes from the perspective of strengthening the primary care offered to the population from Rio Negro.

RESUMEN Objetivos: evaluarlos atributos de la Atención Primaria de Salud, desde la perspectiva de los profesionales de la salud, comparando servicios en el Distrito Especial de Salud Indígena y los Departamentos Municipales de Salud. Métodos: este es un estudio transversal en la región del Alto Rio Negro, Amazonas, con 116 profesionales. Los datos fueron recolectados a través de la Primary Care Assessment Tool. Las puntuaciones se clasificaron (≥ 6.6) - orientación fuerte y (<6.6) - orientación baja. La prueba de chi-cuadrado y de máxima verosimilitud para el análisis cruzado. La comparación entre profesionales de la prueba de Kruskal-Wallis. Resultados: se observó una puntuación general más alta en el Distrito de Salud Indígena (7,2). La misma tendencia se observó individualmente en los atributos esenciales y derivados. Conclusiones: este trabajo puede apoyar estrategias que impacten positivamente el modelo de gestión y los procesos de trabajo desde la perspectiva del fortalecimiento de la Atención Primaria ofrecida a la población de Río Negro.

RESUMO Objetivos: avaliar os atributos da Atenção Primária à Saúde, na perspectiva dos profissionais de saúde, comparando os serviços no Distrito Sanitário Especial Indígena e nas Secretarias Municipais de Saúde. Métodos: trata-se de um estudo transversal, na região do Alto Rio Negro, Amazonas, com 116 profissionais. Os dados foram coletados por meio do Primary Care Assessment Tool. Fez-se a categorização dos escores (≥ 6,6) - forte orientação e (< 6,6) - baixa orientação. O Teste Qui-Quadrado e de máxima verossimilhança para análise dos cruzamentos. A comparação entre os profissionais o Teste de Kruskal-Wallis. Resultados: foi observado escore geral maior no Distrito Sanitário Indígena (7,2). A mesma tendência foi observada individualmente nos atributos essenciais e derivados. Conclusões: este trabalho poderá subsidiar estratégias que impactem positivamente no modelo de gestão e processos de trabalho na perspectiva do fortalecimento da Atenção Primária ofertada à população rionegrina.

General practitioners' use of ICPC diagnoses and their correspondence with patient record notes. / Allmennlegers bruk av ICPC-diagnoser og samsvar med journalnotatene.

BACKGROUND: The quality of the general practitioners' setting of diagnoses using codes from the International Classification for Primary Care (ICPC) is important, because these codes are used for purposes of quality development, research and public health statistics. It is uncertain, however, to what extent these diagnoses present a correct picture of the content of and reasons for the consultations and the prevalence of illness in the population. The objective of this study was to identify the extent to which the general practitioners' use of diagnostic codes correlates with the content of the patient record notes. MATERIAL AND METHOD: A total of 23 general practitioners from five different medical centres in Agder county participated in the study. The patient record notes from all patient contacts over two working days in 2013 were reviewed by two experienced general practitioners who assessed the degree of correspondence between the content of the patient record notes and the concomitant ICPC diagnostic codes. RESULTS: A total of 1 819 patient contact were assessed, and for 1 591 of these (87.5 %) it was possible to assess the correspondence between the patient record notes and the diagnosis. We found good correspondence for 693 (85.3 %) consultations and 321 (69.9 %) simple contacts with issuance of a prescription. For simple contacts with no issuance of a prescription there was good correspondence for 213 (83.9 %), although 144 of a total of 398 (36.2 %) could not be assessed because the patient record notes were absent, too brief or imprecise. INTERPRETATION: The diagnoses made during consultations corresponded well with the patient record notes examined in this study. The results may indicate that caution should be exercised in including simple contacts in the data on diagnoses in public statistics. The findings should be followed up in larger-scale and more representative national studies.

Spatial analysis on tuberculosis and the network of primary health care.

OBJECTIVE: to analyze the spatial distribution of new cases of tuberculosis compared to the location of the Primary Healthcare Units that performed the compulsory notification. METHOD: ecological study conducted in Belém, Pará, with 5,294 new cases of tuberculosis notified to Sistema de Informação de Agravos de Notificação for the period from 2010 to 2014. The cases were georeferenced using the software applications ArcGis 10.2 and TerraView 4.2.2. The techniques of Kernel density and global Moran geostatistics were used. RESULTS: the incidence of tuberculosis cases did not vary significantly between the years studied, however there was a variation in incidence between neighborhoods. Health units that exhibited higher number of notifications can suffer great influence of migration from nearby neighborhoods. CONCLUSION: the spatial dynamics of tuberculosis associated with health services allows to know the areas with increased risk of tuberculosis and the density of notifications of health units.

Taxonomy of the form and function of primary care services in or alongside emergency departments: concepts paper.

Primary care services in or alongside emergency departments look and function differently and are described using inconsistent terminology. Research to determine effectiveness of these models is hampered by outdated classification systems, limiting the opportunity for data synthesis to draw conclusions and inform decision-making and policy. We used findings from a literature review, a national survey of Type 1 emergency departments in England and Wales, staff interviews, other routine data sources and discussions from two stakeholder events to inform the taxonomy. We categorised the forms inside or outside the emergency department: inside primary care services may be integrated with emergency department patient flow or may run parallel to that activity; outside services may be offered on site or off site. We then describe a conceptual spectrum of integration: identifying constructs that influence how the services function-from being closer to an emergency medicine service or to usual primary care. This taxonomy provides a basis for future evaluation of service models that will comprise the evidence base to inform policy-making in this domain. Commissioners and service providers can consider these constructs in characterising and designing services depending on local circumstances and context.

Risk classification for conversion from mild cognitive impairment to Alzheimer's disease in primary care.

There is a pressing need to identify individuals at high risk of conversion from mild cognitive impairment (MCI) to Alzheimer's disease (AD) based on available repeated cognitive measures in primary care. Using data from the Alzheimer's Disease Neuroimaging Initiative (ADNI), we applied a joint latent class mixed model (JLCM) to derive a 3-class solution: low risk (72.65%), medium risk (20.41%) and high risk (6.94%). In the low-risk group, individuals with lower daily activity and ApoEε4 carriers were at greater risk of conversion from MCI to AD. In the medium-risk group, being female, single, and an ApoEε4 carrier increased risk of conversion to AD. In the high-risk group, individuals with lower education level and single individuals were at greater risk of conversion to AD. Individual dynamic prediction for conversion from MCI to AD after 10 years was derived. Accurate identification of conversion from MCI to AD contributes to earlier close monitoring, appropriate management, and targeted interventions. Thereby, it can reduce avoidable hospitalizations for the high-risk MCI population. Moreover, it can avoid expensive follow-up tests that may provoke unnecessary anxiety for low-risk individuals and their families.

Confiabilidade e validade da codificação CIAP-2 por estudantes de medicina / Reliability and validity of ICPC-2-R encoding by medical students / Confiabilidad y validez de la codificación CIAP-2 por estudiantes de medicina

Objetivo: Estimar a confiabilidade e a validade da codificação de motivos de consulta e problemas por estudantes utilizando a Classificação Internacional da Atenção Primária, 2ª edição (CIAP-2). Métodos: Para cada encontro supervisionado durante todo um semestre, três professores médicos de família e comunidade registraram os motivos de consulta e problemas em um questionário usando texto livre. Dois de quatro estudantes de medicina e um professor codificaram cada motivo de consulta ou problema usando a CIAP-2. No começo do estudo, houve duas seções de padronização com três horas de duração, até os professores julgarem que os estudantes estavam prontos para a codificação. Após todos os motivos de consulta e problemas terem sido codificados independentemente, os sete codificadores resolveram os códigos definitivos por consenso. Definiu-se confiabilidade como concordância entre estudantes, e validade como a concordância destes com os códigos definitivos; essa concordância foi estimada com o AC1 de Gwet. Resultados: Após a exclusão dos encontros codificados antes da última sessão de padronização, a amostra consistiu em 149 encontros consecutivos, somando 262 motivos de consulta e 226 problemas. A codificação teve confiabilidade moderada a substancial (AC1 0,805; IC 95% 0,767­0,843) e validade substancial (AC1 0,864; IC 95% 0,833­0,891). C

Objective: To estimate how reliably and validly can medical students encode reasons for encounter and diagnoses using the International Classification of Primary Care, revised 2nd edition (ICPC-2-R). Methods: For every encounter they supervised during an entire semester, three family and community physician teachers entered the reasons for encounter and diagnoses in free text into a form. Two of four medical students and one teacher encoded each reason for encounter or diagnosis using the ICPC-2-R. In the beginning of the study, two three-hour workshops were held, until the teachers were confident the students were ready for the encoding. After all the reasons for encounter and the diagnoses had been independently encoded, the seven encoders resolved the definitive codes by consensus. We defined reliability as agreement between students and validity as their agreement with the definitive codes, and used Gwet's AC1 to estimate this agreement. Results: After exclusion of encounters encoded before the last workshop, the sample consisted of 149 consecutive encounters, comprising 262 reasons for encounter and 226 diagnoses. The encoding had moderate to substantial reliability (AC1 , 0.805; 95% CI, 0.767­0.843) and substantial validity (AC1 , 0.864; 95% CI, 0.833­0.891). Conclusion: Medical students can encode reasons for encounter and diagnoses with the ICPC-2-R if they are adequately trained.

Objetivo: Estimar la confiabilidad y la validez de la codificación de motivos de consulta y problemas de salud por estudiantes utilizando la Clasificación Internacional de Atención Primaria, 2ª edición (CIAP-2). Métodos: Para cada encuentro supervisado durante todo un semestre, tres profesores médicos de familia y comunidad registraron los motivos de consulta y los problemas de salud en un formulario usando texto libre. Dos de cuatro estudiantes de medicina y un profesor codificaron cada motivo de consulta o problema de salud utilizando la CIAP-2. En el comienzo del estudio, se llevaron a cabo dos sesiones de estandarización de tres horas, hasta que los profesores estuvieron seguros de que los estudiantes estaban listos para la codificación. Después de que todos los motivos de consulta y problemas de salud fueran codificados independientemente, los siete codificadores resolvieron los códigos definitivos por consenso. Se definió confiabilidad como concordancia entre los estudiantes y validez como la concordancia de éstos con los códigos definitivos; se estimó esta concordancia con el AC1 de Gwet. Resultados: Después de la exclusión de los encuentros codificados antes de la última sesión de estandarización, la muestra consistió en 149 encuentros consecutivos, que comprendían 262 motivos de consulta y 226 problemas de salud. La codificación tuvo una confiabilidad moderada a sustancial (AC1 0,805; IC 95% 0,767­0,843) y validez sustancial (AC1 0,864; IC 95% 0,833­0,891). Conclusión: Los estudiantes de medicina pueden codificar los motivos de consulta y los problemas de salud con la CIAP-2 si fueran adecuadamente capacitados.

Analytical typology of multiprofessional primary care models.

BACKGROUND: There is only limited evidence to support care redefinition and role optimization processes needed for scaling up of a stronger primary care capacity. METHODS: Data collection was based on a keyword search in MEDLINE, EMBASE and CINAHL databases. Three thousand, two hundred and twenty-nine documents were identified, 1851 met our inclusion criteria, 71 were retained for full-text assessment and 52 included in the final selection. The analysis process was done in four steps. In the end, the elements that were identified as particularly central to the process of transforming primary care provision were used as the basis of two typologies. RESULTS: The first typology is based on two structural dimensions that characterize promising multiprofessional primary care teams. The first is the degree to which the division of tasks in the team was formalized. The second dimension is the centrality and autonomy of nurses in the care model. The second typology offers a refined definition of comprehensiveness of care and its relationship with the optimization of professional roles. CONCLUSIONS: The literature we analyzed suggests there are several plausible avenues for coherently articulating the relationships between patients, professionals, and care pathways. The expertise, preferences, and numbers of available human resources will determine the plausibility that a model will be a coherent response that is appropriate to the needs and environmental constraints (funding models, insurance, etc.). The typologies developed can help assess existing care models analytically or evaluatively and to propose, prospectively, some optimal operational parameters for primary care provision.

Health services management modalities in the Brazilian Unified National Health System: a narrative review of research production in Public Health (2005-2016). / Modalidades de gestão de serviços no Sistema Único de Saúde: revisão narrativa da produção científica da Saúde Coletiva no Brasil (2005-2016).

The current study aimed to systematically analyze trends and priorities in the theoretical and conceptual approaches and empirical studies on specific health services management modalities in the Brazilian Unified National Health System. A narrative review of the literature identified, in 33 publications, the location and nature of services, management models, methodological procedures, and study outcomes. The research deals mainly with the models' conceptual and legal characteristics and management practices, in addition to addressing contracts, procurement, human resources, financing, and control mechanisms. In conclusion, the literature is limited and concentrated in the State of São Paulo, showing little theoretical diversity and methodological weaknesses, while it is nonconclusive as to the superiority of one management model over another. New evaluation studies are needed that are capable of comparing different models and assessing their performance and their effects on the quality of health services' provision, the population's health, and the health system's organization.

Use of SNOMED CT® and LOINC® to standardize terminology for primary care asthma electronic health records.

OBJECTIVES: The burden of asthma ranks among the highest for chronic diseases. Interoperable electronic health records (EHRs) can improve the management of chronic diseases such as asthma by facilitating sharing of data between health care settings along the continuum of care. Terminology such as SNOMED CT® (Systematized Nomenclature of Medicine-Clinical Terms) and LOINC® (Logistical Observation Identifier Names and Codes) are prerequisites for interoperability of EHRs. We sought to determine the extent to which data elements in a validated asthma care map (ACM) are congruent with these terminologies. METHODS: A certified asthma educator entered all 169 elements in the ACM into the SNOMED CT® browser. Matched elements were assigned a concept name, an identification number, and classified into a hierarchy. LOINC® terminology was reviewed for asthma-related pulmonary function tests (PFTs). RESULTS: Forty-two percent of the ACM elements were complete matches to existing SNOMED CT® concepts, 24% partial matches, and 34% unmatched. Specific asthma control parameters were either complete (n = 3) or partial (n = 4) matches, but overall "asthma control" was unmatched. There were 92% complete or partial matches for PFT elements to SNOMED CT® and 83% to LOINC®. Conclusions: The majority of ACM elements are congruent with standardized terminology, enabling EHR interoperability. Future requests for new concepts in SNOMED CT® and LOINC® should be pursued for asthma control parameters paramount to evidence-based practice.

Modalidades de gestão de serviços no Sistema Único de Saúde: revisão narrativa da produção científica da Saúde Coletiva no Brasil (2005-2016) / Modalidades de gestión de servicios de salud en el Sistema Único Salud de Brasil: revisión narrativa de la producción científica de la Salud Colectiva (2005-2016) / Health services management modalities in the Brazilian Unified National Health System: a narrative review of research production in Public Health (2005-2016)

O presente trabalho busca sistematizar tendências e prioridades das abordagens teórico-conceituais e das investigações empíricas sobre modalidades específicas de gestão de serviços no âmbito do Sistema Único de Saúde no Brasil. Foi realizada uma revisão narrativa da literatura que identificou, em 33 publicações, a localização e a natureza dos serviços, os modelos de gestão, os procedimentos metodológicos e os desfechos dos estudos. A produção trata principalmente de aspectos conceituais, legais e práticas gerenciais dos modelos, além de abordar contratos, compras, recursos humanos, financiamento e mecanismos de controle. Concluiu-se que a literatura analisada é restrita, concentrada no Estado de São Paulo, com baixa diversidade de teorias e fragilidades de aportes metodológicos, sendo inconclusiva quanto à superioridade de um modelo de gestão sobre outro. São fundamentais novas pesquisas avaliativas capazes de comparar os diferentes modelos e julgar seus desempenhos e efeitos na qualidade da assistência prestada, na saúde da população e na organização do sistema de saúde.

El presente estudio tuvo como objetivo analizar sistemáticamente las tendencias y prioridades en los enfoques teóricos y conceptuales y estudios empíricos sobre modalidades específicas de gestión de los servicios de salud en el Sistema Único de Salud de Brasil. Una revisión narrativa de la literatura identificó, en 33 publicaciones, la ubicación y la naturaleza de los servicios, los modelos de gestión, los procedimientos metodológicos y los resultados del estudio. La investigación se ocupa principalmente de las características conceptuales y legales y las prácticas de gestión de los modelos, además de abordar los contratos, las adquisiciones, los recursos humanos, el financiamiento y los mecanismos de control. En conclusión, la literatura es limitada y concentrada en el Estado de São Paulo, mostrando poca diversidad teórica y debilidades metodológicas, mientras que no es concluyente en cuanto a la superioridad de un modelo de gestión sobre otro. Se necesitan nuevos estudios de evaluación que sean capaces de comparar diferentes modelos y evaluar su desempeño y sus efectos sobre la calidad de la provisión de servicios de salud, la salud de la población y la organización del sistema de salud.

The current study aimed to systematically analyze trends and priorities in the theoretical and conceptual approaches and empirical studies on specific health services management modalities in the Brazilian Unified National Health System. A narrative review of the literature identified, in 33 publications, the location and nature of services, management models, methodological procedures, and study outcomes. The research deals mainly with the models' conceptual and legal characteristics and management practices, in addition to addressing contracts, procurement, human resources, financing, and control mechanisms. In conclusion, the literature is limited and concentrated in the State of São Paulo, showing little theoretical diversity and methodological weaknesses, while it is nonconclusive as to the superiority of one management model over another. New evaluation studies are needed that are capable of comparing different models and assessing their performance and their effects on the quality of health services' provision, the population's health, and the health system's organization.

Diagnostic strategies for urinary tract infections in French general practice.

OBJECTIVES: We aimed to describe the diagnostic management procedures for detection of urinary tract infections in general practice and their correlated factors. PATIENTS AND METHODS: We analyzed data from the ECOGEN study on urinary tract infections, collected in France between November 2011 and April 2012. This national cross-sectional study was carried out in general practices. Data was coded according to the International Classification of Primary Care. RESULTS: A total of 340 consultations or home visits were held for urinary tract infections. The five most frequent diagnostic procedures were (in descending order) clinical examination (67.6%), urine cytobacteriological examination (UCBE) (47.9%), urine dipstick test (15.6%), blood test (8.5%), and imaging (6.5%). No urine dipstick test or UCBE was performed in 43% of cases. Factors correlated with diagnostic procedures were age and gender of patients, annual number of consultations held by family physicians, and duration of consultation. CONCLUSION: Family physicians did not comply with guidelines on diagnostic management for detection of urinary tract infections. We hypothesized that this non-compliance could be due to the family physicians' environment and characteristics, and to clinical practice guidelines.

Atenção Primária à Saúde: um ensaio sobre conceitos aplicados aos estudos nacionais / Primary Health Care: an essay on concepts applied to national studies

Resumo: O Brasil está passando por uma orientação normativa do Ministério da Saúde no sentido de fazer uma reforma da Atenção Primária à Saúde (APS) orientada à Estratégia Saúde da Família (ESF), com adesão dos especialistas das instituições de ensino e pesquisa, para transformá-la em uma porta de entrada resolutiva do sistema de saúde. Este estudo parte da premissa de que o país ainda vive um contexto em que não há separação clara entre papéis específicos dos diferentes tipos de serviços de saúde. Objetivou-se fornecer evidências de que a tendência em avaliar a APS no Brasil, tendo como referência única a ESF, limita a determinação precisa do universo de serviços de saúde que potencialmente contemplam as características definidas internacionalmente como inerentes à APS. Busca-se também indicar possibilidades alternativas de análise e aplicação de seus conceitos aos estudos nacionais. Conclui-se que, se por um lado os conceitos de APS estão bem definidos na literatura, há a constatação de que seu uso é imperfeito para alguns contextos locais e há necessidade de abordagens mais consistentes e racionais, capazes de identificar os serviços de saúde que operam em sintonia com a APS e de mensurar seus atributos essenciais.

Abstract: Brazil is going through a normative guidance of the Ministry of Health in order to make a reform of Primary Health Care (PHC) oriented to the Family Health Strategy (FHS), with support of experts from educational and research institutions, to turn it into a resolutive gateway to the health system. This study assumes that the country still lives a context where there is no clear separation between specific roles of different types of health services. It aimed to provide evidence that the tendency to assess the PHC in Brazil, only by reference to the FHS, is limiting the accurate determination of the health services universe that potentially include the features internationally defined as inherent to the PHC. The aim is to also indicate alternative possibilities for analysis and application of its concepts to national studies. We conclude that if on one hand PHC concepts are well defined in the literature, there is evidence that its use is imperfect to some local contexts and there is a need for more consistent and rational approaches, able to identify the health services operating in line with the PHC and measure its essential attributes.

Concordancia entre sistemas de estratificación e identificación de pacientes crónicos complejos en Atención Primaria / Concordance between stratification systems and identification of patients with multiple chronic diseases in Primary Care

Objetivo. Conocer la prevalencia de pacientes crónicos complejos en el ámbito de Atención Primaria utilizando los criterios de pluripatología y los Clinical Risk Groups y el grado de concordancia entre estos 2 sistemas de identificación de los pacientes que precisan gestión de caso. Material y método. Estudio observacional transversal de 240 pacientes, seleccionados por muestreo aleatorio de 16 cupos asistenciales de 2 centros de salud de Atención Primaria de un área sanitaria. Solicitado consentimiento informado para acceder a su historia clínica electrónica con fines de investigación. Se registró la edad, el sexo, el estado de salud según los Clinical Risk Groups, nivel de gravedad, los criterios de pluripatológico e índice de Charlson por su médico durante la práctica clínica. Se excluyeron 3 pacientes por datos incompletos. Resultados. La prevalencia de pacientes pluripatológicos, siguiendo los criterios del Ministerio de Sanidad entre los demandantes, fue del 4,1% (IC 95% 2,1-7,3). La frecuencia de pacientes con Clinical Risk Groups de alto riesgo denominados G3 en la estrategia de cronicidad de la Comunidad Valenciana fue del 7,5% (IC 95% 4,7-11,7), que sumó los pacientes estado de salud 6 con nivel de complejidad 5 y 6 y los estados de salud 7, 8 y 9. La concordancia entre ambas clasificaciones fue baja con un índice kappa 0,17 (IC 95% 0-0,5). Conclusiones. Las prevalencias no difirieron significativamente de lo esperado y la concordancia entre ambas estratificaciones fue muy débil, no seleccionando a los mismos pacientes de alta complejidad para gestión de casos (AU)

Objective. To determine the prevalence of patients with multiple chronic diseases in Primary Care using the multiple morbidity criteria and Clinical Risk Groups, and the agreement in identifying high-risk patients that require case management with both methods. Material and method. A cross-sectional study was conducted on 240 patients, selected by random sampling of 16 care quotas from two Primary Health Care centres of a health area. Informed consent was obtained to access their electronic medical records for the study, and a record was made of age, sex, health status of Clinical Risk Groups, severity, multiple morbidity criteria, and Charlson index by physicians during clinical practice. Three patients were excluded due to incomplete data. Results. The prevalence of patients with multiple chronic diseases following the criteria of the Ministry of Health among users was 4.11 (95% CI; 2.13-7.30). The frequency of patients with high risk Clinical Risk Groups (G3) in the chronicity strategy of Valencian Community was 7.59 (95% CI; 4.70-11.70), which includes patients with health status 6 and complexity level 5-6, and health status 7, 8, and 9. Agreement between the two classifications was low, with a kappa index 0.17 (95% CI; 0-0.5). Conclusions. The prevalence did not differ significantly from that expected, and the agreement between the two stratifications was very weak, not selecting the same patients for highly complex case management (AU)