Benefits of a clinical pathway in total knee arthroplasty / Beneficios de um programa de cuidados clínicos em artroplastia total de joelho

ABSTRACT Objective: Demonstrate whether a multiprofessional Clinical Pathway Program in Total Knee Arthroplasty (CPPA) contributesto optimizing hospital care. Method: Retrospective study of medical data of care indicators in 310 patients divided into two groups: A- who underwent arthroplasty in the last biennium before the introduction of the CPPA (n=144) and group B- who underwent TKA in the biennium after the introduction of the CPPA (n=166). Results: Postoperative showed a significant difference in favor of group B over group A for hospitalization time in days 4.33 ± 2.79 and 5.4 ± 1.67 (p<0.001), time of prophylactic antibiotic in hours 28.13 ± 33.77 and 81.49 ± 40.91 (p<0.001), referral to the intensive care unit 40.9% and 73.4% (p<0.001), initiation of thromboprophylaxis within 24 hours 97.9% and 82.5% (p<0.001), use of elastic stockings and/or intermittent compression prescribed for thromboprophylaxis 89.5% and 31.2% (p<0.001), initiation of rehabilitation within 24 hours 90.1% and 66.1% (p<0.001), readmissions within 30 days 4.1% and 3% (p = 0.76), readmissions 90 days 2.7% and 6.6% (p = 0.183), transfusions 5.5% and 15.2% (p = 0.033). Conclusion: The implementation of a multiprofessional CPPA contributed to the implementation of care protocols, favoring greater patient safety. Level of Evidence III; Retrospective Comparative Study.

RESUMO Objetivo: Demonstrar se um Programa de Cuidados Clínicos multiprofissional em Artroplastia Total de Joelho (PCCA) contribui para a otimização assistencial hospitalar. Método: Estudo retrospectivo em prontuários de indicadores assistenciais em 310 pacientes divididos em dois grupos: A- submetidos a artroplastia no último biênio antecessor a introdução do PCCA (n=144) e grupo B- submetidos a ATJ no biênio após a introdução do PCCA (n=166). Resultados: Indicadores pós-operatórios mostraram diferença significativa a favor do grupo B sobre o grupo A para tempo de hospitalização em dias 4,33 ± 2,79 e 5,4 ± 1,67 (p<0,001), tempo de antibiótico profilático em horas 28,13 ± 33,77 e 81,49 ± 40,91 (p<0,001), encaminhamento para unidade de terapia intensiva 40,9% e 73,4% (p<0,001), início da tromboprofilaxia dentro de 24h 97,9% e 82,5% (p<0,001), uso de meias elásticas e/ou compressão intermitente prescritos para tromboprofilaxia 89,5% e 31,2% (p<0,001), tempo para iniciação da reabilitação em 24h 90,1% e 66,1% (p<0,001), readmissões em 30 dias 4,1% e 3% (p = 0,76), readmissões 90 dias 2,7% e 6,6% (p = 0,183), transfusões 5,5% e 15,2% (p = 0,033). Conclusão: A implementação de um PCCA multiprofissional contribuiu para o cumprimento dos protocolos assistenciais favorecendo maior segurança para os pacientes. Nível de Evidência III; Estudo Retrospectivo Comparativo.

Determinantes de la gestión del riesgo en salud en el Régimen Subsidiado en Colombia: estudio cualitativo

Introducción: El Régimen Subsidiado (RS) del sistema de salud colombiano tiene problemáticas estructurales que no han sido solucionadas y son pocos los estudios que profundizan en la explicación de estas. Objetivo: Explorar la experiencia en la dirección estratégica y gestión operativa y financiera de este régimen, sus aspectos operativos y de gestión del riesgo en esta población, así como las diferencias percibidas frente al Régimen Contributivo. Metodología: Estudio cualitativo. Se utilizó el análisis del discurso desde la perspectiva sociohermenéutica como técnica analítica. Se entrevistaron diez participantes, entre directivos de aseguradoras del RS y gestores del sistema de salud. Las entrevistas fueron grabadas y anonimizadas, previo consentimiento informado. Resultados: Emergen tres patrones discursivos que explican la gestión del riesgo en el RS y su diferenciación con el contributivo. Estos patrones se conectan por medio del rol de los determinantes sociales de la salud como ordenador principal de los procesos de salud-enfermedad y de atención en este régimen. A su vez, estas condiciones de vida son las que determinan de manera importante el perfil epidemiológico, acceso, costo de la atención y en general la forma cómo se consumen los servicios de salud por la población afiliada. Discusión: La literatura del aseguramiento en salud reporta que la gestión del riesgo es una función central y supone un ejercicio estratégico para el adecuado manejo de la siniestralidad para optimizar el uso de la Unidad de Pago por Capitación (UPC) asignada. Los hallazgos muestran que los determinantes sociales de la salud no están siendo tenidos en cuenta como ordenador para la atención, por lo tanto, la gestión del riesgo se centra en la atención de patologías en estados avanzados. Conclusiones: los actores perciben que en general, la situación de salud de los afiliados en este régimen es más grave, más complicada y con mayor carga, lo cual genera una tensión en materia de suficiencia de la unidad per cápita. Existe una ausencia discursiva sobre el rol del modelo de atención y su correlación con las necesidades de esta población.

Introduction: The subsidized regime (SR) of the Colombian health system has structural problems that have not yet been resolved and there is a lack of studies that allow the understanding of most of them. The aim of this study was to explore with stakeholders of the subsidized regime the experience about strategic, financial, and health risk management and the differences perceived with the contributory regime. Methods: A qualitative study was performed; the analytic technique used was the discourse analysis under socio-hermeneutic perspective. 10 participants were interviewed, among them directors of insurance companies of SR and health care system managers. The interviews were recorded, prior informed consent, and analyzed according to the discourse analysis. Finding: Three discursive patterns emerged that explain risk management in SR and its differentiation from contributory regime. These patterns are connected through the role of the social determinants of health as the main axis that explain the health-disease and care processes in this regimen. At the same time, these living conditions are what determine the epidemiological profile, access, cost of care and, in general, the way in which health services are consumed by the affiliated population. Discussion: The health insurance literature reports that risk management is a central function, and it is a strategic exercise for the proper management of claims to optimize the use of resources, however, the findings show that the social determinants of health are not being taken into account as a key element for healthcare organization, therefore, risk management focuses on care for pathologies in advanced stages. Conclusions: The actors perceive that the health situation in this regime is more severe, more complicated and with a greater burden disease, which generates a tension in terms of sufficiency of the Per Capita Unit. There is a discursive absence on the role of the care model and its correlation with the needs of this population.

Evaluative Research on Pharmacist-managed Diabetes Care: Focus on Self-Monitoring of Blood Glucose / Investigación Evaluativa sobre Atención a la Diabetes Gestionada por los Farmacéuticos: Enfoque del Automonitoreo de la Glucosa en Sangre

ABSTRACT Objective: Pharmacists have not demonstrated the ability to manage chronic diseases such as Type 2 Diabetes Mellitus, which is an ongoing problem in Trinidad and Tobago. The primary objective was to demonstrate that pharmacists can assist patients to achieve at least a 1% decrease in glycosylated haemoglobin (HbA1c). Methods: A randomized, controlled Pharmacist Evaluative Research Study compared the efficacy of pharmacist-managed care (the intervention), and routine standard management (control) of poorly controlled (abnormal HbA1c, blood pressure, blood glucose and lipid panel) adult diabetic patients. Participants in the intervention group met with the pharmacist at their respective primary care sites on a regular basis for an assessment of adherence to medications, barriers to adherence and education. Control group participants consisted of patients receiving routine care by their primary physician but with no direct intervention by the pharmacist except for the filling of prescriptions. Results: Seventy-five patients were initially recruited. Of these, 48 (20 intervention and 28 control) met the inclusion criteria. It was only possible to analyse the result from 20 patients: 14 (70%) intervention and 6 (21.4%) control because of incomplete collected data. A minimum decrease of at least 1% HbA1c was obtained by 8 (57%) intervention participants compared to 2 (33%) in the control group; while HbA1c remained unchanged for two participants, each in the intervention and control groups (14% and 33%, respectively). Conclusion: We could not conclude any statistical or clinical significance in the paper as the data could only be analysed using descriptive methods. Building a culture of research among pharmacists may promote the use of pharmacists as adjunctive healthcare practitioners to achieve better patient outcomes.

RESUMEN Objetivo: Los farmacéuticos no han demostrado ser capaces de manejar el tratamiento de enfermedades crónicas como el tipo 2 Diabetes mellitus, que es un problema actual en Trinidad y Tobago. El objetivo principal fue demostrar que los farmacéuticos pueden ayudar a los pacientes a lograr al menos una disminución del 1% en hemoglobina (Hba1C). Métodos: Un Estudio de Investigación Evaluativa Farmacéutico controlado aleatorio, comparó la eficacia de la atención gestionada por los farmacéuticos (intervención) y el manejo estándar de rutina (control) de pacientes diabéticos adultos con pobre control (niveles anormales de hemoglobina glicosilada, presión arterial, glucosa en sangre, y perfil lipídico). Los participantes en el grupo de intervención se reunieron de manera regular con el farmacéutico en sus respectivos centros de atención primaria para evaluar el cumplimiento con los medicamentos, así como los obstáculos a la observancia y la educación. Los participantes del grupo de control eran pacientes que recibían atención de rutina de parte de su médico primario, pero sin intervención directa del farmacéutico, excepto para el llenado de prescripciones. Resultados: Setenta-cinco pacientes fueron reclutados inicialmente. De estos, 48 (20 de intervención y 28 de control) cumplían los criterios de inclusión. Debido a que los datos recopilados estaban incompletos, sólo fue posible analizar el resultado de 20 pacientes: 14 (70%) de intervención y 6 (21.4%) de control. Una disminución mínima de al menos 1% de HbA1C fue obtenida por 8 (57%) participantes de intervención en comparación con 2 (33%) en el grupo de control, mientras que el HbA1C permaneció inalterado para 2 participantes, cada uno en los grupos de intervención y control (14% y 33%, respectivamente). Conclusión: Los datos apoyan la hipótesis de que la gestión de los farmacéuticos como profesionales complementarios de la salud, posibilita lograr mejores resultados en los pacientes, a diferencia de lo que ocurre en ausencia de tal gestión.

Effects of the Integrated Stress Management Program on Stress and Depression in Psychiatric Inpatients / 정신간호학회지

PURPOSE: The purpose of this study was to test the effects on stress and depression by developing and implementing an integrated stress management program for inpatients in the psychiatric closed ward. METHODS: The study was a one-group pretest-posttest design. A total of 36 patients in the closed ward participated in this study. Data were collected through self-report questionnaires to measure hospital stress and depression. Data were analyzed by using t-tests and one-way ANOVA with SPSS/WIN 21.0. RESULTS: Integrated stress management program was designed based on Lazarus and Folkman stress-appraisal-coping model. Total of eight 1-hour sessions were delivered for four weeks in the group. There were significant differences in the inpatient stress scores before and after the intervention. However, the integrated stress management program showed some reduction in depression but did not show signifiant differences statistically. CONCLUSION: Our study findings confirm that the use of the integrated stress management program can reduce stress of the patients, that enable them to stabilize their minds at hospitalization. However, further study is needed to confirm the effects on depression. Thus, it would be beneficial to provide psychiatric nursing intervention tailored to psychiatric patients' symptoms, especially for reducing inpatient stress.

Strategy of Basic Medical System Reform Under the Perspective of Institutional Supply / 中国医院管理

Financial funding model of basic medical service reform should shift from single paying attention to supply of medical services to coordination concern about medical service output.No fault medical damage compensation system should be included in the budget arrangement of national financial investment.In the face of high incidence of medical damage,the center of medical tort liability system should be changed from relief patients to prevention of medical injury.Negligence litigation system has a profound negative impact on health care system.Most attention to this negative influence should be paid when efforts are made to promote managed care.It is necessary to change basic medical service system linking with current medical tort liability system so as to design from a more macro perspective of system supply.

A workshop on asthma management programs and centers in Brazil: reviewing and explaining concepts / Programas e centros de atenção a asmáticos no Brasil; uma oficina de trabalho: revisitando e explicitando conceitos

Objective: To report the results of a workshop regarding asthma management programs and centers (AMPCs) in Brazil, so that they can be used as a tool for the improvement and advancement of current and future AMPCs. Methods: The workshop consisted of five presentations and the corresponding group discussions. The working groups discussed the following themes: implementation of asthma management strategies; human resources needed for AMPCs; financial resources needed for AMPCs; and operational maintenance of AMPCs. Results: The workshop involved 39 participants, from all regions of the country, representing associations of asthma patients (n = 3), universities (n = 7), and AMPCs (n = 29). We found a direct relationship between a lack of planning and the failure of AMPCs. Based on the experiences reported during the workshop, the common assumptions about AMPCs in Brazil were the importance of raising awareness of managers; greater community participation; interdependence between primary care and specialized care; awareness of regionalization; and use of medications available in the public health system. Conclusions: Brazil already has a core of experience in the area of asthma management programs. The implementation of strategies for the management of chronic respiratory disease and their incorporation into health care system protocols would seem to be a natural progression. However, there is minimal experience in this area. Joint efforts by individuals with expertise in AMPCs could promote the implementation of asthma management strategies, thus speeding the creation of treatment networks, which might have a multiplier effect, precluding the need for isolated centers to start from zero. .

Objetivo: Relatar os resultados de uma oficina de trabalho sobre programas e centros de atenção a asmáticos (PCAAs) no Brasil para que possam servir como instrumento para melhoria e avanço dos PCAAs existentes e criação de novos. Métodos: A oficina de trabalho constituiu-se de cinco apresentações e discussões em grupos. Os grupos de trabalho discutiram os seguintes temas: implementação de uma linha de cuidado em asma; recursos humanos necessários para os PCAA; recursos necessários para financiar os PCAA; e manutenção do funcionamento dos PCAAs. Resultados: A oficina envolveu 39 participantes de todas as regiões do país, representando associações de asmáticos (n = 3), centros universitários (n = 7) e PCAAs (n = 29). Evidenciou-se uma relação direta entre a ausência de planejamento e o insucesso dos PCAAs. Com base nas experiências brasileiras elencadas durante a oficina, as premissas comuns foram a importância da sensibilização do gestor, maior participação da comunidade, interdependência entre a atenção primária e a especializada, observação da regionalização e utilização dos medicamentos disponíveis no sistema público de saúde. Conclusões: O Brasil já tem um núcleo de experiências na área programática da asma. A implementação de uma linha de cuidado em doenças respiratórias crônicas e sua inclusão nas redes de saúde parecem ser o caminho natural. Porém, a experiência nessa área ainda é pequena. Agregar pessoas com experiência nos PCAAs na elaboração da linha de cuidado em asma encurtaria tempo na criação de redes de atenção com possível efeito multiplicador, evitando que se partisse do zero em cada local isolado. .

Os usuários e a transição tecnológica no setor de saúde suplementar: estudo de caso de uma operadora de plano de saúde / /Users and the technological transition in the supplemental health sector: case study of a health insurance plan company

O artigo apresenta os resultados de investigação realizada junto a usuários do case management, programa desenvolvido por uma empresa de medicina de grupo para o cuidado de pacientes vivendo situação de alta vulnerabilidade. Buscou-se construir uma perspectiva na qual a experiência do usuário, ao invés de representar apenas uma informação adicional ou superposta à qualidade dos serviços, é considerada parte indissociável do arranjo estudado, com potência para iluminar qualidades e contradições internas. Os resultados mostram como os pacientes dão alto valor aos cuidados recebidos, com especial ênfase no vínculo criado com a equipe responsável, mesmo que apenas por via telefônica. Ao mesmo tempo, conseguem perceber a dupla face regulação/modelo assistencial presente no arranjo tecnológico estudado, sobretudo o quanto o forte viés econômico de redução de custo que preside sua operacionalização impacta na qualidade final do cuidado.

This paper presents the results obtained from qualitative research conducted with a group of users involved in Case Management, a program which was developed by a company of a medical group to provide healthcare for patients in situations of high vulnerability. The study sought to create a perspective in which the experience of the user, instead of representing merely additional or superimposed information upon the quality of services, is considered an inherent part of the arrangement under scrutiny, with the ability to highlight its internal qualities and contradictions. The results show how patients attribute high value to the healthcare they receive, with special emphasis on the bond that is created with the health team in charge, even when contact is only by telephone. Simultaneously, they are able to perceive the double-sided aspect presented by the regulation/assistance model found in the technological arrangement at issue, notably in relation to the prominent role played by the economic bias towards cost reduction - which lies in the forefront of its operationalization - and the final impact it has upon the final quality of healthcare.

Competencias esenciales para la gestión en red / Essential competences for the management of health care networks

We suggest that in order to fulfill the health needs of the majority of the Chilean population, which is beneficiary ofthe public health system, essential organizational skills should be developed for network administration among Self-administered Hospitals, Network Manager and Primary Health Care facilities. Self-administered Hospitals should be competent in managing service options according to their strategy for development, reference and counter-reference mechanisms and waiting lists, to optimize queuing. The Network Manager should be competent in demand management that is regulated, investments management that determines future development in terms of population needs and stakeholders' management, which is a political viability type of management. Finally, the Primary Health Care manager should be competent in demand management as a strategic partner of the Network Manager, community participation and management of interlinked areas, articulating social networks and sanitary impact management. At each level and within levels, there are crossroads that promote synergies. Based on the development of essential skills, a practice with strategic intentions, organization managers will develop team work skills.

O papel necessário da Agência Nacional de Saúde Suplementar na regulação das relações entre operadoras de planos de saúde e prestadores de serviços / The necessary role of the National Supplementary Health Agency in the regulation of relations between managed care companies and service providers

Este artigo trata do papel regulatório que caberia à Agência Nacional de Saúde Suplementar (ANS) desempenhar, a partir do resultado de um conjunto de pesquisas e estudos sobre as práticas de microrregulação exercidas pelas operadoras de planos de saúde sobre os prestadores hospitalares privados. O trabalho se baseia em diversos estudos e, especialmente, nos resultados da pesquisa de Ugá et al. (2007), cujos resultados permitiram a problematização de questões relativas à necessidade de regular alguns elementos da relação entre operadoras e prestadores hospitalares, fundamentais para a garantia do acesso e da qualificação da atenção recebida por clientes de operadoras de planos privados de saúde; e também relativas à importância que os prestadores hospitalares privados possuem para o SUS. Busca-se, assim, a partir dos estudos sobre o tema, refletir tanto sobre o papel regulador a ser desempenhado pela ANS nas relações contratuais entre operadoras e prestadores, quanto sobre o papel que ao SUS caberia exercer.

This paper discusses the regulatory role that would fit the National Supplementary Health Agency (ANS), from the results of researches and studies on the practices of micro-regulation performed by private managed care companies on hospital providers they contract. It is based on several studies, especially on the research by Ugá el al (2007), whose results allowed the questioning of issues related to the necessary regulation of some elements of the relationship between health managed care companies and hospital providers, key to ensuring access and qualification of health care received by customers of those companies, as well as the importance that hospital providers have for the public health system, SUS. The paper aims, therefore, from the studies on the subject, to reflect on the regulatory role to be played by ANS in the contractual relations between managed care companies and providers and on the role that would fit to the SUS on this matter.

Implantação do programa de controle da tuberculose na Unidade Básica de Saúde HCPA/ Santa Cecília / Implantation of the tuberculosis control program in the Basic Health Unit HCPA/Santa Cecília / Implantación del programa de control de tuberculosis en Unidad Básica de Salud HCPA/Santa Cecília

Introdução: a regionalização do controle da tuberculose (TB) é uma das metas da Vigilância (CGVS) buscando reduzir os casos de abandono do tratamento e aumentar a taxa de diagnóstico. A análise dos resultados prévios das áreas a serem regionalizadas é importante para manter e ampliar a qualidade do controle da tuberculose, além de ser uma das etapas iniciais do planejamento da atenção à saúde. Objetivo: a regionalização do atendimento à TB na área da UBS HCPA visa: (1) descentralizar a estratégia de diagnóstico e tratamento da TB; (2) implantar um sistema coordenado de atenção com foco na atenção primária; (3) georreferenciar os pacientes para otimizar a vigilância local; (4) contribuir para o treinamento dos médicos residentes em medicina de família HCPA na área de gestão dos programas da atenção primária; e (5) contribuir na redução das taxas de abandono ao tratamento. Materiais e Métodos: Fase 1 - realizou-se a estimativa do número de casos, georreferenciamento dos casos notificados e a análise da coorte utilizando os dados históricos da região de abrangência da UBS HCPA no período de janeiro de 2004 até julho de 2008, data da implantação do serviço regionalizado buscando os indicadores de atenção deste período. Fase 2 ­ Foram criados fluxogramas de rastreamento, diagnóstico e tratamento e foi iniciado o atendimento sob supervisão. Resultados: a incidência média de TB nessa região é de aproximadamente 0,5/100.000hab/ano. Foram realizados mapas georeferenciados dos casos. Foram notificados 88 pacientes entre 1/2004 a 7/2008, sendo 55,7% da forma pulmonar (idade 39,6 ±16,8 anos), 37,5% extra-pulmonar (idade 48,2 ±17,5 anos) e o restante, formas mistas. Quanto ao local de diagnóstico: 1% na atenção primária, 89% na atenção secundária e os demais na atenção terciária. Nos casos de TB pulmonar, a baciloscopia foi positiva em 57,1% e não realizada em 18% dos casos. Com relação ao tratamento as taxas foram 75,1%, para cura e 8,5% de abandono. Os dados do início da implantação (3 meses) mostram a pesquisa de 25 sintomáticos respiratórios por mês, o diagnóstico de um caso novo e a busca ativa de 100% dos faltosos. Conclusões: os resultados prévios da área mostram taxas de sucesso e de abandono abaixo das metas estabelecidas. A taxa de diagnóstico na atenção primária é baixa. Em função disso a descentralização deve ser acompanhada por um aumento do rastreamento dos sintomáticos respiratórios e busca ativa dos contatos, visando aumentar o diagnóstico e o desenvolvimento de tratamento supervisionado (ADOT) buscando reduzir o abandono.

Introduction: The regionalization of control of tuberculosis (TB) is one of the aims of the vigilance (CGVS) seeking to reduce the cases of treatment abandonment and to raise the diagnostic rate. The analysis of previous results of the areas yet to be regionalized is important to maintain and amplify the quality of TB control, besides being one of the first steps of the attention to health plan. Objective: the regionalization of TB treatment in the USB HCPA area aims to: decentralize the diagnostic strategy and TB treatment; implant a system attention coordinated with focus on the primary attention; georeference the patients in order to optimize the local vigilance; contribute to the training of the resident doctors in HCPA family medicine in the management area of the primary attention programs; and contribute in the reduction of the treatment abandonment rate. Materials and Methods: Phase 1 ­ an estimate of the number of cases was done, notified cases were georeferenced and an analysis of the cohort was carried out, using the regional historic data on the UBS HCPA reach in the period from January 2004 to July 2008, implantation date of the regionalization service searching for the attention indicators of this period. Phase 2 ­ tracking, diagnosis and treatment fluxograms were created, and attendance under supervision was initialized. Results: The average incidence of TB in this region is of approximately 0.5/100,000 inhabitants/year. Georeferenced maps of the cases were made. Eightyeight patients were notified between 1/2004 to 7/2008, being 55.7% pulmonary (age 39.6 ±16.8 years), 37.5% extra pulmonary (age 48.2 ±17.5 years) and the rest, mixed forms. As for the location of diagnostic: 1% in primary attention, 89% in secondary attention and the remainder in the tertiary attention. In the cases of pulmonary TB, the smear was positive in 57.1% and not done in 18% of the cases. Regarding the treatment, the rates were 75.1% of cure and 8.5% of abandonment. The data from the start of implantation (3 months) show the research of 25 respiratory symptomatic per month, the diagnosis of one new case and the active search by 100% of the absent subjects. Conclusions: The previous results of the area show rates of success and of abandonment below the established goals. The ratio of diagnosis in primary attention is low. Because of that, the decentralization should be accompanied with a raise on tracking of respiratory symptomatic patients and active search of contacts, aimimg to raise the diagnosis and development of supervised treatment (ADOT), seeking to reduce abandonment.

Introducción: La regionalización del control de la tuberculosis (TB) es una de las metas de la vigilancia (CGVS), buscando reducir los casos de abandono del tratamiento y aumentar la tasa de diagnóstico. El análisis de los resultados previos de las áreas regionales es importante para mantener y ampliar la cantidad del control de la tuberculosis, además de ser una de las etapas iníciales del planeamiento de la atención a la salud. Objetivo: La regionalización del atendimiento a la TB en área da UBS HCPA visa: (1) descentralizar la estrategia del diagnóstico y tratamiento de la TB; (2) implantar un sistema coordinado de atención focalizado en atención primaria, (3) analizar los pacientes para optimizar la vigilancia local; (4) contribuir para o entrenamiento de los médicos residentes en medicina familiar HCPA en área de gestión de los programas de atención primaria; (5) contribuir en la reducción de las tasas de abandono al tratamiento. Materiales y Métodos: Fase 1- se realizó la estimativa del número de los casos, localización de los casos notificados y el análisis da coorte utilizando los datos históricos de la región de cobertura de la UBS HCPA en período de enero de 2004 hasta Julio de 2008, dada la implantación del servicio regionalizado buscando los indicadores de atención de este período.Fase2- Han sido creados fluxogramas de rastreamento, diagnósticos y tratamiento, y ha sido indicado en atendimiento bajo supervisión. Resultados: La incidencia media de TB en esta región es próximamente 0,5/100.000 hab/año. Han sido realizados mapas pesquisa de los casos. Se notificaron 88 pacientes entre 1/2004 a 7/2008, siendo 55,7% de la forma pulmonar (edad 39,6 a 16,8 años), 37,5% extra pulmonar (edad 48,2 a 17,5 años) y el restante, formas mistas. En cuanto al local de diagnóstico: 1% en la atención primaria, 89% en la atención secundaria y los además en la atención terciaria. En los casos de TB pulmonar, la baciloscopia ha sido positiva en 57,1% y no realizadas en 18% de los casos. En relación al tratamiento las tasas son de 75,1% para cura y 8,5% de abandono. Los datos del inicio de la implantación (3meses) indican la pesquisa de 25 sintomáticos respiratorios al mes, el diagnostico de un caso nuevo y la búsqueda activa de 100% de los faltosos. Conclusiones: Los resultados previos del área indican tasas de suceso y de abandono abajo de las metas establecidas. La tasa de diagnósticos en la atención primaria es baja. Así, la descentralización debe ser acompañada por un aumento del rastreamento de los sintomáticos respiratorios y la búsqueda activa de los contactos, visando aumentar el diagnóstico y el desarrollo del tratamiento supervisionado (ADOT) buscando reducir el abandono

Reference of and comparison between managed care and traditional medical insurance in America / 中华医院管理杂志

Managed care insurance is growing into the mainstream health insurance model in the United States. The differences between this and the traditional health insurance lie in their economic model, their autonomy of consumers in their choices of suppliers, their economic risk exposure for clinicians, their effect on utilization review and their impact to clinical decision-making. Managed care can only, in terms of cost constraints, affect or limit the autonomy of medical decision, instead of making decisions in lieu of clinicians. Under managed care, both the professional risk of clinicians and health benefits of consumers are exposed to obvious negative influence. In the meantime, the model is facing growing difficulties in the future for the market itself. In this regard, prudence is required to introduce managed care in China.

Procedimentos e percepções de profissionais e grupos atuantes em mercados de planos de saúde no Brasil / Procedures and perceptions of professionals and groups acting in the Brazilian health plan market

O objetivo do estudo é analisar o modo como, no Brasil, operadoras de planos e seguros de saúde, serviços hospitalares e médicos organizam o acesso aos serviços de saúde, e que mecanismos utilizam para economia de custos e de decisões. A análise faz uso da literatura de regulação em saúde e da estratégia do managed care. A partir de uma seleção intencional de operadoras baseada em número de beneficiários, modalidade organizacional e abrangência geográfica, foram selecionadas amostras probabilísticas de médicos e de serviços hospitalares. Os dados foram obtidos através de questionários com representantes das operadoras, médicos e hospitais a elas credenciados. Os resultados sugerem que as relações entre operadoras, médicos e hospitais se estabeleceram em bases herdadas do antigo sistema previdenciário, com pagamento predominante de serviços por tabelas fixas e contas abertas. Mecanismos mais complexos de financiamento, de compartilhamento de riscos e de busca pela eficiência são pouco experimentados. São frágeis os mecanismos de redução de agravos, assim como os incentivos ao uso adequado das tecnologias. Fatores moderadores de consumo ou barreiras de acesso são o meio mais comum de controle de custos. Pode-se concluir que a agenda do managed care é incipiente no caso brasileiro.

This study analyzes the mechanisms used in Brazil by health plan and insurance operators, hospitals and physicians for organizing the access to health care services and their strategies towards cost reduction and decision-making. The study is based on the literature about regulation of the health services, with special focus on micro-management and managed care. From an intentional sample of health care organizations selected according to the number of beneficiaries, organizational modality and geographic criteria we selected probabilistic samples of doctors and hospital services. Data were collected through questionnaires applied to key informants from health care operators and affiliated doctors and hospitals. Results suggest that the relationships between health care organizations, physicians and hospitals follow basically patterns inherited from the former social security system, mainly with fixed pricing and open account payments. More complex financing mechanisms, risk sharing and efficiency strategies are of minor interest. Mechanisms for risk reduction and encouragement of adequate use of technologies are weak. Cost control is mainly based on co-payment and barriers to access to the services. We conclude that in Brazil managed care is still in its beginning.

Resultados de un sistema de atención privado basado en un modelo de salud familiar en Chile / Results of a private primary health system based on a family health care model in Chile

Background: The health care network of a University in Chile started a family based primary health care system using pre paid model as financing. Aim: To describe the results of this family Health Care Center. Material and Methods: Between 1999 and 2006, the Pontificia Universidad Catolica-Health Network offered a family care plan characterized by a preferential access to a Family Care Center (CSF), that coordinated and solved all health care needs. Several indicators and perception of satisfaction were used to assess the results of this plan, in 2003 and 2004. Results: During the study períod, 5,402 people were attended. Seventy three percent of these were aged between 15-44 years. The waiting lapse was less than 48 hours for medical appointments and less than 30 days for programmed surgical procedures. The coverage of preventive actions varied from 26 percent of mammographies among women between 25 to 69 years old to 100 percent for healthy child care among newborns. Thirty one percent of diabetics achieved a glycosilated hemoglobin of less than 7 percent and 19 percent of hypertensive subjects achieved blood pressure values below 135/85 mmHg. Family physicians had 2.3 appointments per person per year and solved 85 percent of the medicalproblems that motivated the consultation. In average, 88 percent of interviewed subjects evaluated the attention received as very good or excellent. Conclusions: The application of this model in the private sector achieves measurable health care results with a good degree ofclient satisfaction.

Efectos de la reforma en salud en las acciones de control de tuberculosis en el Valle del Cauca, Colombia

Se describen efectos de la implementación del Sistema General de Seguridad Social en Salud - SGSSS, en la década de los noventa, sobre las acciones de control de tuberculosis en el Valle del Cauca, Colombia. El estudio se llevó a cabo en siete municipios del departamento mediante un abordaje complementario de técnicas de recolección y análisis de información cualitativa y cuantitativa. Se presentó una reducción en el papel de planeación, control y regulación de las acciones de tuberculosis por parte de las entidades estatales. Los nuevos actores y las nuevas fuentes de financiación no produjeron los efectos positivos esperados en las acciones de control de tuberculosis; la cantidad y calidad de las acciones de tuberculosis se redujeron por el efecto de la reforma sectorial. Se concluye que la implementación del SGSSS afectó de manera negativa las acciones de control de tuberculosis.

Effects of the health sector reform upon tuberculosis control interventions in Valle del Cauca, Colombia Implementation of the General System of Social Security in Health (GSSSH) was initiated for the control of tuberculosis (TBC) in the state of Valle del Cauca, Colombia, between 1991- 2000. A study of its effects was centered in 7 municipalities of Valle del Cauca with a complementary set of qualitative and quantitative techniques for data collection and analysis. A reduction in planning, control and regulation of TBC activities by state agencies was observed. New administrative structures and new funding sources did not produce the expected positive effects on tuberculosis control. Instead, the quantity and quality of tuberculosis control activity were reduced as a consequence of the health sector reform. In conclusion, GSSSH implementation affected negatively tuberculosis control activity.

Home care in America

This article discuss the American history and the evolution of home health care that has taken place over the last few years