Surgical Treatment of Carotid-cavernous Fistula Performed through the Brazilian Unified Health System

Introduction The carotid-cavernous fistula (CCF) is an abnormal communication between the arterial carotid system and the cavernous sinus. In most cases, spontaneous fistulas are due to the rupture of intracavernous carotid artery aneurisms. Traumatic fistulas occur in 0.2% of head injuries, and 75% of all CCFs are caused by automobile accidents or penetrating traumas. Objective To identify the data regarding the number of annual procedures, hospital expenses, length of hospital stay, and the number of deaths of patients admitted by the Brazilian Unified Health System (SUS, in the Portuguese acronym), in the period between 2007 and 2017, using the surgical code of the surgical treatment for CCF. Methods The present was an ecological study whose data were obtained by consulting the database provided by the Department of Computer Sciences of the Brazilian Unified Health System (Datasus, in Portuguese). Results A total of 85 surgical procedures were performed for the treatment of CCFs from January 2007 to October 2017 through the Unified Health System (SUS, in Portuguese), and there was a reduction of 71.42% in this period. The annual incidence of patients undergoing this surgical treatment during the period observed remained low, with 1 case per 13,135,714 in 2007, and 1 case per 51,925,000 in 2017. Conclusion Despite the low annual incidence of the surgical treatment of CCFs performed by the SUS in Brazil in the period of 2007­2017, based on the data obtained on the average length of stay and expenditures in hospital services, it is necessary that we develop an adequate health planning.

Metodología para la estimación de costos directos de la atención integral para enfermedades no trasmisibles / Methodology for estimating total direct costs of comprehensive care for non-communicable diseases

RESUMEN Enfermedades como la diabetes mellitus (DM) y la hipertensión arterial (HTA) generan altos costos y son la causa más frecuente de mortalidad en la región de las Américas. En el caso del Perú, dados los cambios demográficos y epidemiológicos, y particularmente el aumento alarmante del sobrepeso y la obesidad, la carga de estas enfermedades tiene un crecimiento constante que implica la necesidad de asignar cada vez más recursos financieros a los servicios de salud. Los costos de la atención integral de estas enfermedades y sus complicaciones representan una carga económica que debe ser considerada por las instituciones de salud al elaborar su presupuesto. Con ese propósito, la Organización Panamericana de la Salud (OPS) ha apoyado al Ministerio de Salud (MINSA) con la realización de un estudio para la estimación de estos costos. En el presente artículo se describe esquemáticamente la metodología desarrollada para la estimación de los costos directos en la atención integral de la DM e HTA en los servicios de salud del MINSA y gobiernos regionales.

RESUMEN Diseases like diabetes mellitus (DM) and hypertension (HT) generate high costs and are the most common cause of mortality in the Americas. In the case of Peru, given demographic and epidemiological changes, particularly the alarming increase in overweight and obesity, the burden of these diseases is constantly increasing, resulting in the need to budget more financial resources to the health services. The total care costs of these diseases and their complications represent a financial burden that should be considered very carefully by health institutions when they draft their budgets. With this aim, the Pan American Health Organization has assisted the Ministry of Health (MINSA) with a study to estimate these costs. This article graphically describes the methodology developed to estimate the direct costs of comprehensive care for DM and HT to the health services of MINSA and regional governments.

Atenção integral à saúde e diversidade sexual no Processo Transexualizador do SUS: avanços, impasses, desafios / Comprehensiveness and sexual diversity in the Brazilian norm in the process of health care for transsexuals: progress, dilemmas, challenges

A publicação da norma sobre o Processo Transexualizador no SUS, apesar de refletir importante conquista do segmento populacional de transexuais, denuncia a complexidade do avanço dos direitos sexuais no campo da Saúde Coletiva. O artigo tem por objetivo a consideração crítica dos avanços, impasses e desafios na instituição dessa política pública de saúde, discutindo a ambivalência no processo de construção da norma técnica. Resgata duas correntes paralelas de inserção do debate sobre saúde de transexuais no Ministério da Saúde: a judicialização e o compromisso com o programa de governo Brasil sem Homofobia. Sinaliza a qualidade parcial do avanço conquistado pela publicação da norma, já que estabeleceu, ao mesmo tempo em que afirmou o direito à saúde para transexuais, campos de exclusão para possíveis beneficiários das mesmas ações de saúde previstas, especificamente as travestis. A hipótese sustentada é a da incidência da heteronormatividade e do binarismo de gênero como fator limitador da democratização dessa política de saúde.

The Brazilian norm that establishes the conditions for the health care for transsexuals, despite reflecting important achievements of this population, reveals the complexity of the advancement of sexual rights in the field of public health. This paper aims to review the advances, challenges and dilemmas in the establishment of this public health policy, discussing the ambivalence in the process of building the technical standard. It releases two parallel chains of the inclusion of the debate about transgender health care in the Health Ministry: the judicialization and the committment with the government program "Brazil without Homophobia". It indicates the partial progress achieved by the publication of the standard, as it established exclusion areas for potential beneficiaries of the same set of health actions, specifically the transvestites, at the same time it stated the right to health care for transsexuals. The hypothesis sustained is that heteronormativity and the binary of gender work as limiting factors for the democratization of the health policy.

The impact of 'comprehensive geriatric assessment (CGA)' implementation on the effectiveness and cost (CEA) of healthcare in an acute geriatric ward.

AIM: to investigate the cost effectiveness of CGA in an acute geriatric ward. METHODS: a non-randomized controlled trial was carried out at Dr. Cipto Mangunkusumo General Hospital from January to December 2005. The inclusion criteria were elderly patients with geriatric syndrome. Exclusion criteria were advanced malignancy, APACHE II score > 34,in-hospital mortality in the first 24 hours, move to another ward before completing CGA management, the presence of dementia. After patients were allocated into CGA and non-CGA group, effectiveness was assessed using ADL/WHO Unescap score, days of hospitalization, proportion of re-hospitalization, survival, quality of life score (EQ5D),patients and nurses satisfaction score. Cost effectiveness analysis was done using TreeAge-Pro 2004 software program. RESULTS: the length of hospitalization was shorter in the CGA group than in non-CGA group (10.99 [0.79] days vs.20.16 [2.62] days; p=0.00). At the end of treatment, mean of ADL score changes was significantly higher in CGA group than non-CGA group. Mean of WHO-Unescap score changes in CGA group was higher than non-CGA group (0.71[0.04]vs 0.61 [0.04]; p=0.09). EQ5D-VAS score was also higher in CGA group (0.79[0,01] vs 0.75[0.01]; p=0,01). Survival proportion in CGA group was lower than non-CGA group(80.37% vs 86.92%; p>0.05). Rehospitalization proportion was higher in non-CGA group than in CGA group (21.5%vs 11.21%; p 0.04). Patient's satisfaction level was higher in CGA group (193.38 [1.25] vs 177.47 [3.04]; p=0.00).Nurse satisfaction level was also higher in CGA group than non-CGA group but not statistically significant (225.06[7.08] vs 220.06[8.26]; p=0.65).Mean of healthcare cost in non-CGA group was higher than in CGA group (Rp. 9,746,426.00 [1,180,331] vs Rp 4,760,965.00 [338,089]). Cost effectiveness analysis indicated that CGA was superior to conventional approach because for each point score of QALD's, total cost was lower in geriatric acute care unit than in conventional ward(Rp 418,199.00 vs Rp 628,695.00). Moreover, QALD's in CGA group was better than in non-CGA group (24.1 vs 22.8; p= 0.03). CONCLUSION: the CGA approach is more cost effective compared to conventional approach. Quality adjusted life days are better in CGA group than in non-CGA group although survival is not statistically different. In CGA group, length of hospitalization was shorter, functional status and patient satisfaction is better in general. Working satisfaction of nurses in CGA group was not lower than in non CGA group.

Partnered care in the Bahamas: A model of advanced healthcare delivery for developing countries / Cuidados mediante asociación en las bahamas: un modelo avanzado de prestación de servicios de salud Para los países en vías de desarrollo

OBJECTIVE: To assess the delivery of advanced specialized medical care using The Partnered Care Model as a means of providing affordable access to all, irrespective of ability to pay. DESIGN AND METHODS: A retrospective analysis of all persons presenting to a specialized, private, cardiac unit, The Bahamas Interventional Cardiology Center (BICC), over an 8.5-year period from March 1996 to September 2004 was conducted. The Bahamas Heart Center's Discounted Service System had been applied since inception to all patients in three groups including insured patients billed at 100of the fee schedule of The Medical Association of the Bahamas for the procedures performed, private self-pay and government patients billed at 75and 50respectively. Their respective distribution and contributions to total revenue was analyzed. A series of financial models were constructed taking into consideration variables that could influence the percentages of revenues collected from each sector and the number of individuals served RESULTS: One thousand five-hundred and forty-two patients received services in BICC over the 8.5 year period (56males and 44females age range: 0.25 - 96 years, with mean age of 55.7 years). One thousand eight-hundred and eighty-eight patient-procedures were performed, with 51insured generating 69total revenue, 18Private producing 16Revenue, and 31Government patients generating 15. Financial models were created to predict revenue behaviour in various scenarios. CONCLUSION: Partnered Care is a viable alternative for Governments (Ministries of Health) of developing countries to provide costly specialized healthcare to their populations at minimal expense and capital outlay. Partnered Care reduces the otherwise overwhelming burden of healthcare cost to governments, particularly in developing countries, by sharing the burden of care between the private, user and government sectors.

OBJETIVO: Evaluar la prestación de servicios médicos especializados avanzados, usando el modelo de cuidados mediante asociación, como medio de proporcionar acceso económico a todos, con independencia de su capacidad de pago. DISEÑO Y MÉTODOS: Se llevó a cabo un análisis retrospectivo de todas las personas que acudieron a una unidad privada de cardiología – The Bahamas Interventional Cardiology Center (BICC) – por un periodo del 8.5 años, a saber, de marzo de 1996 a septiembre de 2004. El sistema de servicio de descuentos del Centro Cardiológico de Bahamas, había sido aplicado desde el principio a todos los pacientes en tres grupos. Los mismos comprendían: los pacientes con seguro – quienes pagaban el 100% de la suma estipulada por la Asociación Médica de Bahamas para los procedimientos realizados, los pacientes privados auto-financiados, y los pacientes con asistencia gubernamental, que abonaban 75% y 50% respectivamente. Se analizó su distribución respectiva y sus contribuciones al ingreso total. Se construyó una serie de modelos financieros tomando en consideración las variables que podrían influir en los porcentajes de ingresos percibidos por cada sector así como el número de individuos atendidos. RESULTADOS: Mil quinientos cuarenta y dos pacientes recibieron servicios en el BICC por espacio de 8.5 años (56% hombres y 44% mujeres). El rango de edad: 0.25–96 años, con una edad media de 55.7 años). Se realizaron mil ochocientos ochenta y ocho procedimientos por los cuales el 51% constituido por los asegurados generó un ingreso total del 69%; el 18% formado por los privados produjo un ingreso del 17%; y el 31% representado por los pacientes gubernamentales generó una entrada del 15%. Se crearon modelos financieros a fin de predecir el comportamiento de los ingresos en diversos escenarios. CONCLUSIÓN: El cuidado mediante asociación es una alternativa viable, mediante la cual los gobiernos (los ministerios de salud) de los países en vías de desarrollo pueden brindar a sus respectivas poblaciones, servicios de salud especializados – que de otra forma serían costosos – con costos y desembolso de capital mínimos. Los cuidados mediante asociación reducen la carga del costo de la atención a la salud para los gobiernos – carga que de otra forma resultaría realmente abrumadora, especialmente en los países en vías de desarrollo. Esto se logra mediante el procedimiento de compartir la carga de los cuidados médicos entre los tres sectores referidos – el de los usuarios, el privado, y el gubernamental.

Alcances de las visitas domiciliarias efectuada en la zona de Tupac Amarú, independencia por los estudiantes de la Universidad Peruana Cayetano Heredia / Domiciliary visit achievements effected in Tupac Amaru, independencia by the students of Cayetano Heredia Peruvian University

Se muestran alcances de visitas domiciliarias efectuadas en Túpac Amaru, por estudiantes de la Universidad Peruana Cayetano Heredia durante mayo de 1990, basados en hojas censales y hojas de visitas domiciliarias de 433 familias.Se efectuaron 63 visitas (12 por ciento de las familias). 81 por ciento fueron efectivas: en el cerro 94.7 por ciento, en el plano 60 por ciento. Se visitó al 85 por ciento de gestantes y 28.9 por ciento de niños menores de un año.Asentamientos Humanos con menos de 4 años de antiguedad y familias que viven a menos de 1000 metros del centro de salud fueron mas visitados. 76.1 por ciento de visitas tuvo un solo motivo registrado, mayormente seguimiento de pacientes.El cumplimiento del llenado de datos censales fue 69.8 por ciento.Se incluye que las visitas domiciliarias fueron altamente efectivas; más frecuentemente en zonas de cerro, menos antiguas y mas cercanas.Gestantes y niños menores de un año fueron los grupos mas visitados.La mayoria de visitas tuvo un motivo registrado: seguimiento de pacientes.Utilizar formularios para registrar la visita brinda buena información del trabajo efectuado