Management of pain in cancer patients- lessons from practices during the COVID-19: a qualitative study of cancer care providers' perspectives.

BACKGROUND: The ongoing COVID-19 pandemic has impacted health systems globally and affected managing many chronic conditions, including cancer. This study aimed to explore the perceptions of multi-disciplinary cancer care providers on how cancer pain management was affected by the COVID-19 pandemic. METHODS: Participants were eligible if they were cancer care providers of any specialty and discipline from two tertiary hospitals in Australia. Data were collected using semi-structured interviews to explore cancer care providers' perspectives on cancer pain management within COVID-19. Thematic analysis of interview transcripts used an integrated approach that started with inductive coding before coding deductively against a behaviour framework called the COM-B Model, which proposes that 'capability', 'motivation' and 'opportunity' are requisites for any behaviour. RESULTS: Twenty-three providers participated. Five themes were developed and interpreted from the analysis of data, namely: "Telehealth enables remote access to cancer pain management but also created a digital divide", "Access to cancer pain management in the community is compromised due to the pandemic", "COVID-19 negatively impacts hospital resource allocation", "Patients were required to trade off cancer pain management against other health priorities" and "Hospital restrictions result in decreased social and psychological support for patients with cancer pain". CONCLUSIONS: The landscape of cancer pain management in the Australian health system underwent substantial shifts during the COVID-19 pandemic, with lasting impacts. Cancer care providers perceived the pandemic to have significant adverse effects on pain management across multiple levels, with repercussions for patients experiencing cancer-related pain. A more adaptive health system model needs to be established in the future to accommodate vulnerable cancer patients.

Impact of TAILORx on chemotherapy prescribing and 21-gene recurrence score-guided treatment costs in a population-based cohort of patients with breast cancer.

BACKGROUND: The trial assigning individualized options for treatment (Rx) (TAILORx) confirmed the predictive value of the 21-gene recurrence score (RS) assay in hormone receptor (HR)-positive, HER2-negative, node-negative breast cancer and established thresholds for chemotherapy benefit in younger and older patients. Real-world chemotherapy use and RS-guided treatment costs in British Columbia post-TAILORx were examined. METHODS: The authors assembled 3 cohorts of HR-positive, HER2-negative, node-negative patients with breast cancer defined by diagnosis: before RS funding (cohort 1 [C1]: January 2013-December 2013), after introduction of public RS funding (cohort 2 [C2]: July 2015-June 2016), and after TAILORx results (cohort 3 [C3]: July 2018-June 2019). Chemotherapy use was compared between cohorts by age and RS. Budgetary impacts of RS testing on chemotherapy costs were evaluated pre- and post-TAILORx. RESULTS: Among the 2066 patients included, chemotherapy use declined by 19% after RS funding was introduced and by an additional 23% after TAILORx publication (P = .001). Reduction in chemotherapy use was significant for RS 11-20 tumors (C3 vs C2, P = .004). There was no significant change in chemotherapy use in patients >50 years old (C2:12% vs C3:10%, P = .22). RS testing was associated with higher cost savings post-TAILORx, except in patients 70 to 80 years old, where testing led to excess costs when adjusting for the low rate of RS-concordant chemotherapy prescribed. CONCLUSIONS: TAILORx has had population-based impacts on chemotherapy prescribing in intermediate RS tumors and patients ≤50 years old. The lower clinical use of RS and increased spending in patients 70-80 years old highlights the importance of careful selection of older candidates for high-cost genomic testing. LAY SUMMARY: The 21-gene recurrence score (RS) test helps predict whether patients with hormone-positive, HER2-negative, lymph node-negative breast cancer are likely to benefit from chemotherapy. The recent trial assigning individualized options for treatment (Rx) (TAILORx) found that patients with intermediate RS tumors did not benefit from chemotherapy. The authors assessed whether TAILORx results translated to real-world changes in chemotherapy prescribing patterns. In this study, chemotherapy use decreased by 23% after TAILORx, with the greatest reductions seen among intermediate RS tumors and younger patients. In contrast, RS testing had lower clinical value and increased treatment costs in elderly patients, which requires further study to ensure optimal care for this age group.

A rapid review of end-of-life needs in the LGBTQ+ community and recommendations for clinicians.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer plus (LGBTQ+) adults face challenges accessing end-of-life care. Understanding the experiences of LGBTQ+ persons within the end-of-life context is crucial in addressing their needs and supporting equity at end of life. AIM: Review recent literature documenting the experiences of LGBTQ+ adults nearing end-of-life, identifying needs, barriers to care, and translating this into clinical recommendations. DESIGN: A rapid review design was chosen for prompt results. The process was streamlined by limiting the literature search to peer-reviewed articles, dissertations, theses, by date and language. Data collection used a predetermined set of items based on Meyer's Minority Stress and Bronfenbrenner's Ecological Models including participants' voices, needs, and barriers. Thematic analysis of collected data was conducted and presented results in a narrative summary. DATA SOURCES: We searched six electronic databases (PubMed, Medline, ProQuest Dissertations and Theses A&I, ProQuest Dissertations and Theses, Open Access Theses and Dissertations, CINAHL, and Google Scholar) for articles published from 2016 to 2020. RESULTS: We included and appraised for quality 33 articles. We uncovered three latent themes: systemic barriers, a lack of lived experience within the literature, and treatment of LGBTQ+ as one homogeneous group. CONCLUSIONS: The hybrid Meyer's Minority Stress and Bronfenbrenner Ecological model elucidated how stressors and social contexts may impact LGBTQ+ adults when accessing end-of-life care. Incorporating LGBTQ+ cultural competence training into continuing education and ensuring that LGBTQ+ individuals participate in the development of end-of-life care programming may better attend to the needs of this population.

Prevalence and characteristics of patients with heart failure needing palliative care.

BACKGROUND: Few hospitals and heart failure (HF) clinics offer concurrent palliative care (PC) together with life-prolonging therapies. To know the prevalence of patients in HF clinics needing PC and useful tools to recognize them are the first steps to extending PC in those settings. However, it is still unknown whether tools commonly used to identify patients with HF needing PC can correctly distinguish them. Two systematic reviews found that the NECesidades PALiativas (NECPAL) tool was one of the two most commonly used tools to asses PC needs in HF patients. Therefore, we assessed 1) the prevalence of PC needs in HF clinics according to the NECPAL tool, and 2) the characteristics of the patients identified as having PC; mainly, their quality of life (QoL), symptom burden, and psychosocial problems. METHODS: This cross-sectional study was conducted at two HF clinics in Colombia. We assessed the prevalence of PC in the overall sample and in subgroups according to clinical and demographic variables. We assessed QoL, symptom burden, and psychosocial problems using the 12-Item Short-Form Health Survey (SF-12), the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Edmonton Symptom Assessment System (ESAS). We compared the results of these tools between patients identified as having PC needs (+NECPAL) and patients identified as not having PC needs (-NECPAL). RESULTS: Among the 178 patients, 78 (44%) had PC needs. The prevalence of PC needs was twice as nigh in patients NYHA III/IV as in patients NYHA I/II and almost twice as high in patients older than 70 years as in patients younger than 70 years. Compared to -NECPAL patients, +NECPAL patients had worse QoL, more severe shortness of breath, tiredness, drowsiness, and pain, and more psychosocial problems. CONCLUSION: The prevalence of PC needs in outpatient HF clinics is high and is even higher in older patients and in patients at more advanced NYHA stages. Compared to patients identified as not having PC needs, patients identified as having PC needs have worse QoL, more severe symptoms, and greater psychosocial problems. Including a PC provider in the multidisciplinary team of HF clinics may help to assess and cover these needs.

[Quality of patient information leaflets on atopic eczema : An analysis using the DISCERN instrument]. / Qualität von Patienteninformationsbroschüren zum atopischen Ekzem : Eine Analyse mithilfe des DISCERN-Instruments.

BACKGROUND: As in other chronic diseases, providing medical information plays a key role in the therapy of atopic eczema. It is already known that information leaflets often do not meet the criteria of evidence-based patient information (EBPI). OBJECTIVE: Therefore, the aim of this study was to examine the quality of information leaflets on atopic eczema. MATERIAL AND METHODS: A total of 35 leaflets were included in the study. They were collected from self-aid groups, from the internet, from general practitioners, from pediatricians and dermatologists as well as from pharmacies in Regensburg. The quality of information provided was assessed using the DISCERN instrument. RESULTS: Almost all of the 35 patient information leaflets assessed had shortcomings, scoring only mid- or low-point in the analysis. None of the leaflets was of excellent quality. Only three leaflets were estimated to contain good quality information. CONCLUSION: Most of the leaflets did not meet the criteria of evidence-based patient information. In conclusion, there may be a lack of quality information about atopic eczema. Improving the existing material and comparing the EBPI standards with the information needs of atopic eczema patients should be topics of future research.

Utility of the NECPAL CCOMS-ICO© tool and the Surprise Question as screening tools for early palliative care and to predict mortality in patients with advanced chronic conditions: A cohort study.

BACKGROUND: The Surprise Question (SQ) identifies patients with palliative care needs. The NECPAL CCOMS-ICO© (NECPAL) tool combines the Surprise Question with additional clinical parameters for a more comprehensive assessment. The capacity of these screening tools to predict mortality is still unknown. AIM: To explore the predictive validity of the NECPAL and SQ to determine 12- to 24-month mortality. DESIGN: Longitudinal, prospective and observational cohort study. SETTING/PARTICIPANTS: Three primary care centres, one general hospital, one intermediate care centre, and four nursing homes. Population cohort with advanced chronic conditions and limited life prognosis. Patients were classified according to SQ and NECPAL criteria and followed for 24 months. RESULTS: Data available to assess 1059 of 1064 recruited patients (99.6%) at 12 and 24 months: 837 patients were SQ+ and 780 were NECPAL+. Mortality rates at 24 months were as follows: 44.6% (SQ+) versus 15.8% (SQ-) and 45.8% (NECPAL+) versus 18.3% (NECPAL-) ( p = 0.000). SQ+ and NECPAL+ identification was significantly correlated with 24-month mortality risk (hazard ratios: 2.719 and 2.398, respectively). Both tools were highly sensitive (91.4, CI: 88.7-94.1 and 87.5, CI: 84.3-90.7) with high negative predictive values (84.2, CI: 79.4-89.0 and 81.7, CI: 77.2-86.2), with low specificity and positive predictive value. The prognostic accuracy of SQ and NECPAL was 52.9% and 55.2%, respectively. The predictive validity was slightly better for NECPAL. CONCLUSION: SQ and NECPAL are valuable screening instruments to identify patients with limited life prognosis who may require palliative care. More research is needed to increase its prognostic utility in combination with other parameters.

Developing from within: ensuring the ambulatory emergency care workforce is fit for purpose.

Emergency healthcare provision is changing, and services need to respond to evolving health economies while providing safe, effective, patient-centred care. Ambulatory care is developing to meet these needs, but workforce planners need to ensure that staff are fit for purpose. To address this, one trust, in partnership with a local university, designed a bespoke in-house, work-based learning package on ambulatory care, which was delivered to registered nurses by practice experts. This article describes the project and discusses the evaluation, which highlighted the benefits of this way of learning for the nurses, the trust and the university, and identified some areas that require development.

[Attitudes towards assisted living inAustria-A qualitative study]. / Einstellungen zum Betreuten Wohnen in Österreich - Eine qualitative Studie.

BACKGROUND: Surveys in German speaking countries identified motives for choosing assisted living, but their importance in the context of decision making remains unclear. AIM: This study aimed to identify types of attitudes towards assisted living among older persons in Austria that result from the interplay of single motives. METHOD: A comparative qualitative study with semi-structured interviews was conduCted in the land Salzburg among residents of assisted living facilities and home dwelling older adults. Data were analysed by using qualitative content analysis according to Mayring and subsequent construction of types. RESULTS: Among residents types of attitudes were "proactive users" who expected more safety or comfort and persons who "moved m due to external circumstances" like taking the opportunity of available place or feeling forced by functional/imitations or be ing influenced by significant others. Types of attitudes among home dwelling older persons were "conditional acceptance';"rejection" and ;'indecisiveness':Vague ideas about assisted living often prevented an informed decision. CONCLUSION: Choice of assisted living only depends to some extent on specific expectations. Better information,advice by significant others and availability of a place may favour a decision to move in.

Muscle invasive bladder cancer: examining survivor burden and unmet needs.

PURPOSE: Although improvements in perioperative care have decreased surgical morbidity after radical cystectomy for muscle invasive bladder cancer, treatment side effects still have a negative impact on patient quality of life. We examined unmet patient needs along the illness trajectory. MATERIALS AND METHODS: A total of 30 patients (26.7% women) treated with cystectomy and urinary diversion for muscle invasive bladder cancer participated in the study. Patients were recruited from the Department of Urology at Mount Sinai and through advertisements on the Bladder Cancer Advocacy Network (BCAN) website between December 2011 and September 2012. Data were collected at individual interviews, which were audiotaped and transcribed. Transcribed data were quantitatively analyzed to explore key unmet needs. RESULTS: At diagnosis unmet informational needs were predominant, consisting of insufficient discussion of certain topics, including urinary diversion options and their side effects, self-care, the recovery process and medical insurance. Unmet psychological needs related to depression, and worries about changes in body image and sexual function were reported. Postoperative unmet needs revolved around medical needs (eg pain and bowel dysfunction) and instrumental needs (eg need of support for stomal appliances, catheters and incontinence). During survivorship (ie 6 to 72 months postoperatively) unmet needs centered around psychological support (ie depression, poor body image and sexual dysfunction) and instrumental support (eg difficulty adjusting to changes in daily living). CONCLUSIONS: Meeting patient needs is imperative to ensure adequate patient involvement in health care and enhance postoperative quality of life. An effective support provision plan should follow changes in patient needs.

A flexible format interdisciplinary treatment and rehabilitation program for chronic daily headache: patient clinical features, resource utilization and outcomes.

OBJECTIVE: To describe the demographics, diagnoses, program duration, human resource utilization and outcomes of patients with chronic daily headache treated in an ambulatory, interdisciplinary, flexible format, treatment and rehabilitation program. BACKGROUND: Research indicates that multidisciplinary care is an effective approach to manage chronic daily headache, but little is known about the resources needed for effective care. METHODS: The study was a secondary data analysis within a cohort design of previously collected data. Patients completed questionnaires and outcome measures on admission and discharge. Diagnoses were extracted from patient charts by professional health records personnel. A central scheduling database provided patient-specific clinician care hours by discipline and type (direct, indirect, group) as well as overall program duration. RESULTS: One hundred and eighteen patients were studied (mean age 41.1 ± 10.4 [x ± SD], 80% female). Sixty-two patients (52.5%) completed the program ("completers"). Migraine was the most common diagnosis. Thirty-six percent of patients had medication overuse. Average pain, mood, disability, and quality of life were significantly improved in completers (P < .001). They utilized 76 ± 45.1 (x ± SD ) total hours of care delivered over a mean of 129.7 ± 66.1 weeks. CONCLUSION: Our study provides evidence that ambulatory, interdisciplinary, flexible format, treatment and rehabilitation programs are effective in the treatment of chronic daily headache, and we provide data on the resources used by our program in the treatment and rehabilitation of these patients.

[What women want: a qualitative study about postnatal midwifery care at home]. / Was Wöchnerinnen wünschen: Eine qualitative Studie zur häuslichen Wochenbettbetreuung nach der Spitalentlassung durch frei praktizierende Hebammen.

In Switzerland, decreases in regular hospital treatment after birth are leading increasingly to mother and child being cared for at home by independent midwives. The research herein was carried out in order to understand the needs of mothers in their home once they leave the hospital and what this midwife provided care consists of. In 2008, eight women from central Switzerland were interviewed on two separate occasions after the birth of their child, and the interviews were analysed using content analysing techniques. Mothers explained that they wanted their baby and themselves to be well cared for. They needed rest and support for recuperation and wished to spend quality time with their new family. The midwifes assisted the mothers to fulfil their needs by counselling, by instructing and by giving information, but they rarely encouraged them to be together as a family. The relationship between midwife and mother turned out to be an important support. Mothers were satisfied if mutual trust was built and if the midwife perceived their needs, respected their autonomy and took the time to be with them. Midwives contribute to the basic well-being of families and support women with medical expertise and ongoing care. Furthermore families need support in general household issues so that new mothers can recover sufficiently.

Surgical Treatment of Valvular Heart Disease in Nigeria: A 6-Year Experience.

Surgical treatment of valvular heart disease in Nigeria, the most populous country in sub-Saharan Africa, is adversely affected by socioeconomic factors such as poverty and ignorance. To evaluate our experience in this context, we identified all patients who underwent surgery for acquired or congenital valvular heart disease at our Nigerian center from February 2013 through January 2019. We collected data from their medical records, including patient age and sex, pathophysiologic causes and types of valvular disease, surgical treatment, and outcomes. Ninety-three patients (43 males [46.2%]; mean age, 38.9 ± 10.0 yr [range, 11-80 yr]) underwent surgical treatment of a total of 122 diseased valves, including 72 (59.0%) mitral, 26 (21.3%) aortic, 21 (17.2%) tricuspid, and 3 (2.5%) pulmonary. The most prevalent pathophysiologic cause of disease was rheumatic (87 valves [71.3%]), followed by functional (20 [16.4%]), congenital (8 [6.6%]), degenerative (5 [4.1%]), and endocarditic (2 [1.6%]). All 3 diseased pulmonary valves had annular defects associated with congenital disease. Surgical treatment included mechanical prosthetic replacement of 92 valves (75.4%), surgical repair of 29 (23.8%), and bioprosthetic replacement of 1 (0.8%). We conclude that, in Nigeria, valvular disease is mainly rheumatic, affects mostly younger to middle-aged individuals, and is usually treated with prosthetic replacement.

The patient categorisation tool: psychometric evaluation of a tool to measure complexity of needs for rehabilitation in a large multicentre dataset from the United Kingdom.

PURPOSE: This first psychometric evaluation of the Patient Categorisation Tool examined its properties as an instrument to measure complexity of needs in a mixed population of patients presenting for specialist neurorehabilitation. MATERIALS/METHODS: Analysis of a large multicentre cohort of patients (n = 5396) from the national clinical dataset representing 63 specialist rehabilitation services across England. Structural validity was examined using exploratory and confirmatory factor analysis. Concurrent and criterion-validity were tested through a priori hypothesized relationships with other validated measures of resource requirements and dependency. RESULTS: All but two items loaded strongly onto a single principal component with Cronbach's alpha 0.88. A total score of ≥30 identified patients with complex (category A) needs with sensitivity 76% and specificity 75%. However, confirmatory factor analysis provided a better fit when the scale was split into two subscales - a 'Cognitive/psychosocial' and a 'Physical' sub-scale (alpha 0.83 and 0.84, respectively). Moderate convergent and discriminant correlations were consistent with hypothesized relationships. CONCLUSIONS: The findings provide some overall support for the Patient Categorisation Tool as a unidimensional tool for measuring complexity of needs for neurorehabilitation, but the subscales may be more suitable for certain groups of patients. Further analysis is now required to evaluate its performance in different conditions. Implications for Rehabilitation A psychometrically robust tool for measuring the complexity of rehabilitation needs has potential value, both at an individual level for treatment planning, and at a population level for planning and commissioning rehabilitation services. The Patient Categorisation Tool now forms part of the United Kingdom national clinical dataset mandated by the National Health Service in England This psychometric analysis from a large national multicentre cohort representing a diverse range of conditions, provides evidence for its validity as a means to identity patients with complex rehabilitation needs requiring specialist rehabilitation.

NEDOCS vs subjective evaluation, ¿Is the health personnel of the emergency department aware of its overcrowding?

INTRODUCTION: An emergency department (ED) is considered to be "overcrowded" when the number of patients exceeds its treatment capacity and it does not have the conditions to meet the needs of the next patient to be treated. This study evaluates overcrowding in the emergency department of a hospital in Colombia. OBJECTIVE: To compare the objective NEDOCS scale with a subjective evaluation by ED health staff in order to evaluate the differences between the two. METHODS: The NEDOCS scale was applied and a subjective overcrowding survey was administered to the medical staff and the charge nurse on duty 6 times per day (6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m. and 9:00 p.m.) for three consecutive weeks. The results were evaluated with a correlation analysis and measurement of agreement. RESULTS: A median NEDOCS score of 137 was obtained for the total data. There was a moderately positive correlation between the NEDOCS and the subjective scales, with a rho of 0.58 (p (0.001). During times when the ED was the most crowded, 87% of the total subjective health staff evaluations underestimated the level of overcrowding. CONCLUSIONS: Health staff do not perceive a risk due to ED overcrowding when the NEDOCS scores correspond to overcrowding categories equal to or over 5 (severely crowded and dangerously crowded), which poses a risk to patient safety and care.

INTRODUCCIÓN: Se considera "Aglomeración" cuando un servicio de urgencias excede el número de pacientes que tiene capacidad de atender o no cuenta con las condiciones para cubrir las necesidades del próximo paciente a ser atendido. Este estudio evalúa el sobrecupo del servicio de urgencias en un hospital de Colombia. OBJETIVO: Comparar la escala objetiva de NEDOCS con la escala subjetiva del personal de salud en el departamento de urgencias para evaluar la diferencia entre ambas. MÉTODOS: Se aplicó la escala NEDOCS y una escala subjetiva de sobrecupo en el servicio de urgencias al personal médico y enfermera jefe de turno durante 3 semanas seguidas, 6 veces al día (6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m., 9:00 p.m.). Se realizaron análisis de correlación y medida de concordancia para evaluar los diferentes resultados. RESULTADOS: La mediana de NEDOCS para el total de datos fue de 137, se presentó una correlación moderadamente positiva entre la escala NEDOCS objetiva con respecto a la subjetiva Rho 0.58 (p <0.001), del total de respuestas en los momentos de mayor congestión el 87% de las valoraciones subjetivas del personal de salud fueron subestimar el nivel de Sobrecupo. CONCLUSIONES: Cuando los niveles de sobrecupo clasificados por NEDOCS son iguales o superiores a nivel 5 (Severamente congestionado y peligrosamente congestionado) el personal de salud no tiene una percepción del riesgo por sobrecupo del departamento de urgencias, lo que conlleva a un riesgo en la seguridad y atención del paciente.

Conhecimentos e práticas educativas de professoras de creches sobre saúde bucal / Knowledge and educational practices of daycare teachers about oral health

O objetivo deste estudo foi identificar os conhecimentos e as práticas educativas de professoras de creches sobre saúde bucal. Trata-se de estudo qualitativo e descritivo, desenvolvido com 28 professoras em Manaus, Brasil. Os dados coletados por meio de entrevista semiestruturada foram sistematizados pela análise de conteúdo temática com apoio do recurso nuvem de palavras. Os resultados mostraram que, dentre as 28 (100%) entrevistadas, 23 concluíram a graduação e 5 possuíam graduação e pós-graduação. A idade variou entre 25 e 67 anos. As professoras tinham conhecimentos acerca de saúde bucal e enfatizaram os maus hábitos das crianças, que levavam à carie, e os hábitos saudáveis. Em relação às práticas educativas, emergiram tecnologias lúdicas. Concluiu-se que os conhecimentos das professoras sobre saúde bucal estavam fortemente ancorados na doença cárie, com indicativos de aproximação do modelo assistencial preventivo.

The aim of this study was to identify the knowledge and educational practices of daycare teachers about oral health. This is a qualitative descriptive study, developed with 28 teachers in Manaus, state of Amazonas, Brazil. Data were collected through semi-structured interviews and systematized by thematic content analysis with the support of the word cloud resource. The results showed that, among the 28 (100%) interviewed, 23 completed the undergraduate program and 5 completed undergraduate and graduate programs. The age ranged from 25 to 67 years. The teachers had knowledge about oral health and emphasized the bad habits of the children, which led to caries, and healthy habits. In relation to educational practices, playful technologies have emerged. The teachers' knowledge about oral health was strongly based on caries disease, with indications of the approximation to the preventive care model.

Outlining the therapeutic itineraries of children with disabilities in the professional health care subsystem / Construcción de los itinerarios terapéuticos de niños con discapacidad en el subsistema profesional de cuidados en salud / Construção dos itinerários terapêuticos de crianças com deficiência no subsistema profissional de cuidados em saúde

ABSTRACT Objectives: to identify the outlining of therapeutic itineraries of families of children with disabilities in the professional health care subsystem. Methods: qualitative research carried out in two specialized services in the state of Ceará, with 41 family members interviewed using the life path technique and reports submitted to descending hierarchical classification and similitude analysis, with the help of the IRaMuTeQ software and the theoretical framework of health care systems. Results: the classes described the families' itineraries in five paths, related to faith, support structures, medical behaviors, professionals, and health services. The professional subsystem stood out as deficient in outlining the therapeutic itinerary for access to health care for children with disabilities, without promoting integration between services in the Care Network. Final considerations: the families' therapeutic itineraries showed homogeneous discourse with themes related to the care of professionals and spiritual aspects.

RESUMEN Objetivos: identificar la construcción de itinerarios terapéuticos de familias de niños con discapacidad, en el subsistema profesional de cuidados con la salud. Métodos: investigación cualitativa realizada en dos servicios especializados en Ceará, con 41 familiares entrevistados por la técnica de trayectoria de vida, con relatos sometidos a clasificación jerárquica descendente y análisis de similitud, con auxilio del software IRaMuTeQ y del referencial teórico de los sistemas de cuidados con la salud. Resultados: las clases describieron el itinerario de las familias en cinco trayectos, relacionados a fe, estructuras de soporte, conductas médicas, profesionales y servicios de salud. El subsistema profesional se destacó como deficitario en el itinerario terapéutico para acceso al cuidado con la salud de niños con discapacidad, sin promover integración entre servicios de la Red de Atención. Consideraciones finales: el itinerario terapéutico de las familias presentó discurso homogéneo con temas relativos al cuidado de los profesionales y aspectos espirituales.

RESUMO Objetivos: identificar a construção dos itinerários terapêuticos das famílias de crianças com deficiência no subsistema profissional de cuidados com a saúde. Métodos: pesquisa qualitativa realizada em dois serviços especializados no estado do Ceará, com 41 familiares entrevistados pela técnica de trajetória de vida, com relatos submetidos à classificação hierárquica descendente e análise de similitude, com auxílio do software IRaMuTeQ e do referencial teórico dos sistemas de cuidados com a saúde. Resultados: as classes descreveram o itinerário das famílias em cinco percursos, relacionados a fé, estruturas de suporte, condutas médicas, profissionais e serviços de saúde. O subsistema profissional destacou-se como deficitário no itinerário terapêutico para acesso ao cuidado com a saúde de crianças com deficiência, sem promover integração entre serviços da Rede de Atenção. Considerações finais: o itinerário terapêutico das famílias apresentou discurso homogêneo com temas relativos ao cuidado dos profissionais e aspectos espirituais.

Necessidades em Saúde dos adolescentes na perspectiva dos profissionais da Atenção Primária à Saúde / Health needs of adolescents from the perspective of Primary Health Care professionals

Resumo O reconhecimento das necessidades em saúde é essencial na elaboração de ações e políticas públicas. Objetivo: analisar o reconhecimento e a satisfação das necessidades em saúde dos adolescentes, a partir da perspectiva de profissionais da Atenção Primária à Saúde. Método: estudo qualitativo, exploratório e descritivo, analisou 15 entrevistas realizadas com profissionais da Atenção Primária à Saúde que atuam no Distrito Sanitário III em Recife, Pernambuco, Brasil, há um ano ou mais. Foi realizada análise de conteúdo com apoio do software webQDA. Resultados: emergiram cinco categorias empíricas: Adolescente e adolescência, Necessidades individuais e do grupo social, Organização política e normativa, Ações profissionais, em equipe e intersetoriais e Potencialidades e limites no atendimento ao adolescente. A compreensão sobre a adolescência é pautada em estereótipos e de frágil articulação aos contextos sociais, econômicos, políticos e históricos. Os profissionais reconhecem como necessidades as demandas compatíveis com as ações programáticas da Atenção Básica sem terem instrumentos suficientes para lidar com as peculiaridades do grupo. A ausência de metas no Plano Municipal de Saúde iguala os adolescentes a outros grupos sociais e lhes oferece o mesmo cardápio de necessidades.

Abstract The recognition of health needs is essential to develop public actions and policies. Objective: to analyze the recognition and the meeting of the health needs of adolescents, from the perspective of Primary Health Care professionals. Method: qualitative, exploratory and descriptive study, which analyzed 15 interviews with Primary Health Care professionals of the III Health District in the municipality of Recife, state of Pernambuco, Brazil, who have worked in Primary Health Care for a year or more. Content analysis was performed using the webQDA software. Results: five empirical categories emerged: Adolescent and adolescence, Individual and social group needs, Political and normative organization, Professional, team and intersectoral actions and Potentials and limits in adolescent care. The concept of adolescence is based on stereotypes and a fragile articulation to social, economic, political and historical contexts. The professionals recognize the demands compatible with the Primary Care programmatic actions as needs, but they do not have enough instruments to deal with the group peculiarities. The absence of goals in the Municipal Health Plan equals adolescents to other social groups and offers them the same menu of needs.

Demanda espontânea e acesso no Sistema Único de Saúde: vivências de usuários da atenção primária / Demanda espontánea y acceso al Sistema Único de Salud: experiencias de usuarios de atención primaria / Spontaneous demand and access to the Unified Health System: The experience of primary care users

Objetivo: compreender as vivências cotidianas de usuários, em demanda espontânea, para o acesso e a acessibilidade no Sistema Único de Saúde na porta de entrada da Atenção Primária à Saúde. Materiais e métodos: estudo de casos múltiplos holístico-qualitativo, fundamentado na sociologia compreensiva do cotidiano, com 60 participantes de município de gran-de porte do estado de Minas Gerais, Brasil. Resultados:a demanda espontânea, no cotidiano, está voltada para o agendamento de consultas, para o aten-dimento médico e para o acesso aos exames, em uma assistência ao adoecimento. Os usuários apresentam dificuldades para o acesso e a acessibilidade às ações e aos serviços. Conclusões: o acesso aos serviços de saúde da Atenção Primária/Estratégia Saúde da Família continua desafiador, restritivo e burocrático, regulado pela demanda espontânea do usuário e pela agenda médica.

Objetivo: comprender las vivencias cotidianas de los usuarios en demanda espontánea en cuanto al acceso al Sistema Único de Salud en la puerta de entrada a la atención primaria en salud. Materiales y métodos: estudio de caso múltiple holístico-cualitativo, basado en la sociología integral de la vida cotidiana, con 60 participantes de un municipio en el estado de Minas Gerais, Brasil. Resultados: la demanda espontánea, en la vida diaria, está dirigida a programar citas, brindar atención médica y gestionar la realización de exámenes, brindado asistencia en caso de enfermedad. Se evidencia que los usuarios tienen dificultades de acceso y accesibilidad a servicios y procedimientos. Conclusiones: el acceso a los servicios de atención primaria en salud (Estrategia de Salud de la Familia) sigue siendo desafiador, restrictivo y burocrático, regulado por la demanda espontánea del usuario y la agenda médica.

Objective: To understand the daily experiences of spontaneous demand users regarding access and accessi-bility to the Unified Health System (Sistema Único de Saúde) through the gateway of primary health care. Materiales and methods: Holistic and qualitative multiple case study based on comprehensive sociology that addresses the every-day life of 60 participants in the state of Minas Gerais, Brazil. Results: Spontaneous demand, in real life, is aimed at scheduling patients appointments, medical care and exams, assisting them in case of illness. Findings show that users have difficulties in accessing services and procedures. Conclusions: Access to primary care services (Family Health Strategy) continues to be challenging, restrictive and bureaucratic, and is regulated by the spontaneous demand of users and the medical agenda

Regulation of Certified Nurse-Midwife Scope of Practice: Change in the Professional Practice Index, 2000 to 2015.

INTRODUCTION: Certified nurse-midwives (CNMs) across the United States are educated in the same core competencies, yet scope of practice varies with state regulation. The Health Resources and Services Administration (HRSA) funded studies published in 1994 and 2004 on the professional practice environment of CNMs, nurse practitioners, and physician assistants, and developed the Certified Nurse-Midwife Professional Practice Index (CNMPPI), a 100-point scoring system of state regulation focusing on 3 domains: legal status, reimbursement, and prescriptive authority. The purpose of this study was to examine changes to CNM regulation between 2000 and 2015 by updating scores to the CNMPPI. METHODS: Individual state CNMPPI scores from 2000 were updated for every year through 2015 by reviewing data published in the American College of Nurse-Midwives (ACNM) quarterly publication Quickening, the annual advanced practice registered nurse legislative updates in the journal Nurse Practitioner, and the ACNM State Legislative and Regulatory Guidance. RESULTS: Mean state scores increased 18%, from 69.7 in 2000 to 79.8 in 2015, and variation between state scores fell. Increases were seen in all 3 domains, with the greatest increase in the domain of prescriptive authority and the smallest in the legal domain. Individual state CNMPPI scores tend to be correlated with scores of adjacent states. DISCUSSION: The CNMPPI can be used to document changes in practice authority of CNMs. The increase in state CNMPPI scores and decrease in variance across states can be interpreted as indicating growth of professional authority and increasing consensus regarding the CNM role. The scoring system needs to be updated to reflect the current health systems environment and to include certified midwives and other midwives meeting the International Confederation of Midwives definition of a midwife. Applications of the CNMPPI to future research are discussed.

Resolution, access, and waiting time for specialties in different models of care

ABSTRACT OBJECTIVE This study aimed to identify the treatment demands coming from primary health care units and, based on that, the demand for referrals to medical specialties in reference services. This study is justified by the scarcity of scientific literature on the subject. METHODS This is a cross-sectional study using secondary data on the treatments and referrals made by the primary health care units, throughout 2014, in a municipality of the State of São Paulo, Brazil. The total population treated in 2014 was considered, resulting in 411,177 treatments. RESULTS Out of all treatments performed, the percentage of referrals was of 4.42%, showing that 95,58% of the problems did not need to be referred to another service. A number of 8,897 referrals were made, to 6,850 users, who were mostly women (60.74%). The mean of referrals per patient was 1.3 (min. 1 and max. 8), and 1,604 patients (23.5%) were referred at least twice. CONCLUSIONS Primary health care services have been responsible for a large number of treatments, whereas the demand for referrals has decreased, suggesting that such services have established themselves as a gateway to the health system and achieved the expected solvability, although the waiting time for some specialties is very long.