Protocolos de encaminhamento da Atenção Básica para a Atenção Especializada: cirurgia torácica e pneumologia / Routing protocols of primary care to specialized care: thoracic surgery and pulmonology

Este material tem como objetivo orientar as equipes que atuam na AB, qualificando o processo de referenciamento de usuários para outros serviços especializados. É uma ferramenta, ao mesmo tempo, de gestão e de cuidado, pois tanto guiam as decisões dos profissionais solicitantes quanto se constitui como referência que modula as avaliações apresentadas pelos médicos reguladores.

The Effect of Asthma Clinical Guideline for Adults on Inhaled Corticosteroids PrescriptionTrend: A Quasi-Experimental Study

In order to increase inhaled corticosteroid (ICS) use and to reduce hospitalization, emergency department visits and ultimately the economic burden of asthma, "Korean Asthma Management Guideline for Adults 2007" was developed. To assess the guideline effects on physician's ICS prescription for asthma, we conducted segmented regression and multilevel logistic regression using National Health Insurance claims database of outpatient visits from 2003 to 2010. We set each quarter of a year as a time unit and compared ICS prescription between before and after guideline dissemination. A total of 624,309 quarterly visits for asthma was observed. The ICS prescription rate before and after guideline dissemination was 13.3% and 16.4% respectively (P < 0.001). In the segmented regression, there was no significant guideline effect on overall ICS prescription rate. In multilevel logistic regression analyses, the effect of guideline on overall ICS prescription was not significant (odds ratio, 1.03; 95% CI, 1.00-1.06). In subgroup analysis, ICS prescription increased in secondary care hospitals (odds ratio, 1.15; 95% CI, 1.02-1.30) and in general hospitals (odds ratio, 1.10; 95% CI, 1.04-1.16). However, in primary clinics, which covered 81.7% of asthma cases, there was no significant change (odds ratio, 0.98; 95% CI, 0.94-1.02). From the in-depth interview, we could identify that the reimbursement criteria of the Health Insurance Review and Assessment Service and patient's preference for oral drug were barriers for the ICS prescription. The domestic asthma clinical guideline have no significant effect on ICS prescription, especially in primary clinics.

Comparison of Korean COPD Guideline and GOLD Initiative Report in Term of Acute Exacerbation: A Validation Study for Korean COPD Guideline

The purpose of this study was to compare the Korean COPD guideline to GOLD consensus report in terms of acute exacerbation. A total of 361 patients were enrolled in this study, and 16.9% of them experienced acute exacerbation during the follow-up. A total of 6.3% of patients in GOLD A, 9.5% in GOLD B, 7.7% in GOLD C and 17.0% of GOLD D experienced exacerbation during the first year of follow-up, respectively (P=0.09). There was no one who experienced exacerbation during the first year of follow-up in the Korean group 'ga'. The 12-month exacerbation rates of Korean group 'na' and 'da' were 4.5% and 16.0%, respectively (P<0.001). We explore the experience of exacerbation in patients with change of their risk group after applying Korean COPD guideline. A total of 16.0% of the patients who were reclassified from GOLD A to Korean group 'da' experienced acute exacerbation,and 15.3% from GOLD B to Korean group 'da' experienced acute exacerbation. In summary, the Korean COPD guideline is useful to differentiate the high risk from low risk for exacerbation in terms of spirometry. This indicates that application of Korean COPD guideline is appropriate to treat Korean COPD patients.

Guía clínica para el diagnóstico y cuidado de niños/adolescentes con bronquiolitis obliterante post-infecciosa, 2009 / Clinical guidelines for the diagnosis and care of children and adolescents with post-infectious bronchiolitis obliterans, 2009

La bronquiolitis obliterante (BO) es un síndrome clínico poco frecuente en niños, caracterizado por la obstrucción crónica al flujo de aire asociado a cambios inflamatorios y distintos grados de fibrosis en la vía aérea pequeña. Si bien existen muchas etiologías, la causa mas frecuente se asocia a infeccionesrespiratorias virales, principalmente adenovirus. No existe un consenso para establecer su diagnóstico; sin embargo, se considera un espectro de síntomas persistentes asociados a un patrón en mosaico, bronquiectasias y atelectasias persistentes. El rol de la biopsia pulmonar ha sido cuestionado por subajo rendimiento, invasividad y complicaciones. No existe un tratamiento específico por lo que elmanejo es soporte. Probablemente la mejor estrategia constituya el empleo de antibióticos en forma agresiva, soporte kinésico y nutricional constante y una precoz rehabilitación pulmonar. Estas guías clínicas representan un esfuerzo multidisciplinario, basado en evidencias actuales para brindarherramientas prácticas para el diagnóstico y cuidado de niños y adolescentes con BO post infecciosa.

Aptitud para la correlación anatomoclínica de neumopatología en alumnos de pregrado / Clinical-pathologyc correlation aptitude of pneumopathology in undergraduate medical students

Objective. 1) To develop and validate an instrument to evaluate the clinical pathology correlation aptitude in pneumopathology (CPCAP). 2) Compare two groups of students: those who had already taken the respiratory pathology course and students that hadn 't. Methods. An instrument with real anatomopathology respiratory cases was developed. The measurement instrument was validated through expert rounds. It included 116 items of the "true", "false", or "don't know" type, with an agreement of 80 % or more in the answerers between the judges. The internal consistency was determined with Spearman Brown proficiency, reaching a value of 0.78. The sample studied was all the groups of each hospital of an organic pathology undergraduate universitary course. Two sampled were taken, students who had already been through respiratory pathology (Group A), and students who hadn't (Group B) Results.The sample studied was of 485 applicants, from 64 different universitary groups. These were divided in two groups, with 245 (A) and 240 (B) students each. Its global medians were 51 and 36 for groups A and B respectively (p < 0.001). In the 55 % of the subgroups when compared individually taking into account each one of the hospital where they study the test results were significantly better in group A. Discussion.In a general way, students in group A show a major development into CPCAP than students in B. However, development is not enough to reach the expected by the educative program. The results suggest that the teachers put greater effort in the correlation between anatomopathological changes and the clinical and paraclinical manifestations of the patients.

Objetivos. 1) Construir y validar un instrumento de medición de la aptitud para la correlación anatomoclínica en neumopatología (ACACN). 2) Comparar la ACACN de alumnos que ya tomaron el curso de patología y quiénes no. Métodos. Se elaboró un cuestionario con base en nueve casos anatomopatológicos con sus correspondientes estudios clínicos. Se estimó su validez conceptual por un grupo de expertos y la confiabilidad mediante correlación de mitades equivalentes. El instrumento quedó conformado por 116 ítems, que obtuvieron un porcentaje de acuerdo con 80 o mayor en las respuestas de los jueces y un coeficiente de .78 de confiabilidad (Spearman-Brown). Se aplicó un diseño ex post facto y las unidades de análisis fueron los grupos de cada hospital sede de un curso universitario de patología orgánica. Mediante un muestreo por cuota se seleccionaron dos muestras de alumnos de pregrado de la carrera de medicina para realizar las mediciones: quienes ya habían cursado la asignatura de patología (A) y quienes no (B). Resultados. Se incluyeron 485 alumnos, 245 de la muestra A y 240 de la muestra B, correspondientes a 64 grupos universitarios. Las medianas globales de ambas muestras fueron 51 y 36, respectivamente (p < 0.001). En la comparación entre muestras de una misma sede hubo diferencia significativa a favor de A en 39% de los grupos. Discusión. Los resultados muestran que la ACACN fue mayor en los alumnos que ya habían cursado la materia, en comparación con los que aún no lo habían hecho, sin embargo, el grado de desarrollo de la misma está lejos de las expectativas del programa educativo y refleja la necesidad de implementar modificaciones en la manera de cómo se imparte la materia.