The Portuguese NHS 2024 reform: transformation through vertical integration.

Vertical integration models aim for the integration of services from different levels of care (e.g., primary, and secondary care) with the objective of increasing coordination and continuity of care as well as improving efficiency, quality, and access outcomes. This paper provides a view of the Portuguese National Health Service (NHS) healthcare providers' vertical integration, operationalized by the Portuguese NHS Executive Board during 2023 and 2024. This paper also aims to contribute to the discussion regarding the opportunities and constraints posed by public healthcare organizations vertical integration reforms. The Portuguese NHS operationalized the development and generalization of Local Health Units management model throughout the country. The same institutions are now responsible for both the primary care and the hospital care provided by public services in each geographic area, in an integrated manner. This 2024 reform also changed the NHS organic and organizational structures, opening paths to streamline the continuum of care. However, it will be important to ensure adequate monitoring and support, with the participation of healthcare services as well as community structures and other stakeholders, to promote an effective integration of care.

Patients' Perspectives on Determinants Avoidable Hospitalizations: Development and Validation of a Questionnaire.

Ambulatory care sensitive conditions (ACSC) can be avoided through effective care in the ambulatory setting. Patients are the most qualified individuals to express the social and individual contexts of their own experience. Thus, understanding why potentially preventable hospitalizations occur is important to develop patient-centred policies or interventions that may reduce them. This study aims to develop and validate a questionnaire to capture the patients' perspective on the causes of the hospitalizations for ACSC. The development of a new questionnaire involved four phases: a literature review, face validity, pre-test, and validation. We conducted a three-step face validity verification to confirm the relevance of the identified determinants and to collect determinants not previously identified by interviewing healthcare providers, representatives of patients' associations, and patients. Determinants were identified through the literature review predominantly in the "Healthcare Access", "Disease self-management", and "Social Support" domains. The validated resulting questionnaire comprises 25 questions, distributed by two dimensions (individual/contextual) covering seven domains and 20 determinants of ACSC hospitalization. Currently, there are no validated instruments as comprehensive and easy to use as the one described in this paper. This questionnaire should provide a base for further language/context validations.

Percutaneous patent ductus arteriosus closure: Twelve years of experience.

INTRODUCTION: Patent ductus arteriosus, a persistent communication between the descending thoracic aorta and the pulmonary artery, is one of the most common congenital heart defects. Transcatheter occlusion is an effective alternative to surgery and is currently standard of care for most patients. The authors present the results from a single center after twelve years of experience using this technique. METHODS: Retrospective analysis of medical records from all patients referred to a tertiary center for percutaneous ductus closure between January 2006 and September 2018. RESULTS: A total of 221 patients were referred, with a mean age of 5.5 years-old (16 patients were infants, with the youngest aged four months). A Nit-Occlud® coil was used 139 times (62.9%), an Amplatzer™ duct occluder 79 times (35.7%), and vascular plugs were used three times. Percutaneous closure was achieved in every treated patient, with 1.4% maintaining residual shunting. Although higher overall coil device implantation was noted, duct occluder usage has been greater since 2011. Of all the coils, 55% were either 4x4 or 5x4 mm, and 73% of all Amplatzer duct occluders were either 6x4 or 8x6 mm, which correlates to the majority of patients having a small to moderately sized ductus. No complications were noted during the procedure, with a 1.8% post-procedure complication rate (one device embolization after 48 hours and three cases of loss of arterial pulse). CONCLUSIONS: Percutaneous patent ductus arteriosus closure was safe and effective in this setting, with a low global complication rate and similar outcomes to most equivalent centers.

ALCAPA syndrome: A rare etiology of cardiac arrest in a teenager.

ALCAPA syndrome is a rare congenital heart disease and a cause of myocardial ischemia in pediatric population. The authors present the case of a 10-year-old girl admitted to the emergency room after experiencing cardiac arrest at school. In the echocardiogram, the inability to identify the origin of the left coronary artery raised the hypothesis of abnormal origin of the left coronary artery from the pulmonary artery (ALCAPA). A CT-scan and a cardiac catheterization were performed confirming the diagnosis. Infants with the syndrome may have myocardial infarction and congestive heart failure. She successfully underwent cardiac surgery. Most undiagnosed patients die within the first year of life, and it is necessary to develop an extensive network of collaterals to ensure survival. ALCAPA syndrome rarely manifests in late childhood, teenagers, and adults and may be an important cause of sudden cardiac arrest.

Early anemia and neonatal morbidity in extremely low birth-weight preterm infants.

BACKGROUND: Extremely low birth-weight (ELBW) preterm infants remain at high risk for mortality and major morbidities, and nearly all need packed red blood cell transfusions within their first weeks of life. The overall objective of this study was to assess the association between anemia at admission to neonatal intensive care unit (NICU) with the neonatal morbidity and mortality in ELBW infants. METHODS: This retrospective study was conducted on 106 patients with ELBW admitted at our level III NICU from January 2006 to December 2015. The subjects were divided into two groups: (1) patients with anemia at admission and (2) patients without anemia. Their characteristics and outcomes were compared. Statistical analysis was performed using the Statistical Package for the Social Sciences software, version 24.0 (IBM New York, USA), and a value of p < 0.05 was considered statistically significant. RESULTS: Of the 106 ELBW, 34 (32%) presented with anemia at admission and 72 (68%) without anemia. Anemia-naive presented mean hemoglobin at the admission of 12.8 ± 1.5 g/dl and nonanemic 16.8 ± 2.1 g/dl, p < .001). The anemic group presented a lower gestational age (26 ± 2 vs. 27 ± 2 SD weeks, p = .025), greater need for inotropic support (52.9 vs. 31.9%, p = .041), longer period of invasive mechanical ventilation (9 vs. 2 days, p = .012), higher FiO2 need (0.8 vs. 0.4, p < .001), more frequent hemodynamically significant patent ductus arteriosus (HS-PDA) (64.7 vs. 41.7%, p = .006) and severe intra-periventricular hemorrhage (IPVH) (41.2 vs. 16.7%, p = 0.005). The multivariate analysis confirmed an association between anemia at admission and HS-PDA (OR = 3.2; 95% CI: 1.1-9.5, p = 0.044) and severe IPVH (OR = 3.3; 95% CI: 1.0-9.9, p = .038). In anemic infants, ionotropic support and IPVH >2 were considered independent factors for mortality. CONCLUSION: In this ELBW series, the presence of anemia at admission to the NICU was associated with HS-PDA and severe IPVH. Preventive strategies for early anemia must be encouraged.

Defining ambulatory care sensitive conditions for adults in Portugal.

BACKGROUND: Ambulatory Care Sensitive Conditions (ACSCs) are health conditions for which adequate management, treatment and interventions delivered in the ambulatory care setting could potentially prevent hospitalization. Which conditions are sensitive to ambulatory care varies according to the scope of health care services and the context in which the indicator is used. The need for a country-specific validated list for Portugal has already been identified, but currently no national list exists. The objective of this study was to develop a list of Ambulatory Care Sensitive Conditions for Portugal. METHODS: A modified web-based Delphi panel approach was designed, in order to determine which conditions can be considered ACSCs in the Portuguese adult population. The selected experts were general practitioners and internal medicine physicians identified by the most relevant Portuguese scientific societies. Experts were presented with previously identified ACSC and asked to select which could be accepted in the Portuguese context. They were also asked to identify other conditions they considered relevant. We estimated the number and cost of ACSC hospitalizations in 2017 in Portugal according to the identified conditions. RESULTS: After three rounds the experts agreed on 34 of the 45 initially proposed items. Fourteen new conditions were proposed and four achieved consensus, namely uterine cervical cancer, colorectal cancer, thromboembolic venous disease and voluntary termination of pregnancy. In 2017 133,427 hospitalizations were for ACSC (15.7% of all hospitalizations). This represents a rate of 1685 per 100,000 adults. The most frequent diagnosis were pneumonia, heart failure, chronic obstructive pulmonary disease/chronic bronchitis, urinary tract infection, colorectal cancer, hypertensive disease atrial fibrillation and complications of diabetes mellitus. CONCLUSIONS: New ACSC were identified. It is expected that this list could be used henceforward by epidemiologic studies, health services research and for healthcare management purposes. ACSC lists should be updated frequently. Further research is necessary to increase the specificity of ACSC hospitalizations as an indicator of healthcare performance.

Congenital systemic venous drainage obstruction: A case report.

BACKGROUND: Vena cava anomalies are rare congenital defects due to incorrect development during fetal life, ranging from minor asymptomatic anatomic variations to complex life-threatening abnormalities. Echocardiography plays a fundamental role in the diagnosis, with advanced imaging techniques allowing detailed anatomic delineation. Invasive cardiology techniques are a promising therapeutic approach, but surgery is probably the best option when diffuse compromise of the systemic veins is present. CASE REPORT: An 8-month-old infant presenting episodes of labial cyanosis and a failure to thrive was diagnosed with severe superior vena cava (SVC) stenosis at the right atrium ostium, with decompression via azygos vein and mild inferior vena cava (IVC) stenosis. The patient was referred for surgery, with IVC enlargement and removal of a fibromuscular tissue band on the anterior aspect of the SVC ostium. At a 6-month follow-up, the patient is asymptomatic, with excellent surgical outcome. To the authors' knowledge, only two cases of congenital SVC stenosis have been previously described.

Comparative research aspects on hospitalizations for ambulatory care sensitive conditions: the case of Brazil and Portugal.

Hospitalizations for ambulatory care sensitive conditions have been used to measure access, quality and performance of the primary health care delivery system, as timely and adequate care could potentially avoid the need of hospitalization. Comparative research provides the opportunity for cross-country learning process. Brazil and Portugal have reformed their primary health care services in the last years, with similar organizational characteristics. We used hospitalization data of Brazil and Portugal for the year 2015 to compare hospitalizations for ambulatory care sensitive conditions between the two countries, and discussed conceptual and methodological aspects to be taken into consideration in the comparative approach. Brazil and Portugal presented similarities in causes and standardized rates of hospitalizations for ambulatory care sensitive conditions. There was great sensitivity on rates according to the methodology employed to define conditions. Hospitalizations for ambulatory care sensitive conditions are important sources of pressure for both Brazil and Portugal, and there are conceptual and methodological aspects that are critical to render the country-comparison approach useful.

Comparative research aspects on hospitalizations for ambulatory care sensitive conditions: the case of Brazil and Portugal / Aspectos de pesquisa comparativa em internações por condições sensíveis à atenção primária: o caso de Brasil e Portugal

Abstract Hospitalizations for ambulatory care sensitive conditions have been used to measure access, quality and performance of the primary health care delivery system, as timely and adequate care could potentially avoid the need of hospitalization. Comparative research provides the opportunity for cross-country learning process. Brazil and Portugal have reformed their primary health care services in the last years, with similar organizational characteristics. We used hospitalization data of Brazil and Portugal for the year 2015 to compare hospitalizations for ambulatory care sensitive conditions between the two countries, and discussed conceptual and methodological aspects to be taken into consideration in the comparative approach. Brazil and Portugal presented similarities in causes and standardized rates of hospitalizations for ambulatory care sensitive conditions. There was great sensitivity on rates according to the methodology employed to define conditions. Hospitalizations for ambulatory care sensitive conditions are important sources of pressure for both Brazil and Portugal, and there are conceptual and methodological aspects that are critical to render the country-comparison approach useful.

Resumo As internações por condições sensíveis à atenção primária têm sido usadas para medir o acesso, a qualidade e o desempenho da atenção primária à saúde, uma vez que o atendimento oportuno e adequado poderia evitar a necessidade de internação. A pesquisa comparativa oferece oportunidade para o processo de aprendizagem entre países. Brasil e Portugal reformaram seus serviços de atenção primária à saúde nos últimos anos, com características organizacionais semelhantes. Utilizamos dados de internação do Brasil e de Portugal para o ano de 2015 para comparar internações por condições sensíveis à atenção primária entre os dois países, e discutimos aspectos conceituais e metodológicos a serem considerados na abordagem comparativa. Brasil e Portugal apresentaram semelhanças nas causas e taxas padronizadas de internações por condições sensíveis à atenção primária. Houve grande sensibilidade nas taxas de acordo com a metodologia empregada para definir as condições. Internações por condições sensíveis à atenção primária são importantes fontes de pressão tanto para o Brasil quanto para Portugal, e há aspectos conceituais e metodológicos que são fundamentais para tornar a abordagem comparativa entre países útil.

Dataset from the Snakes (Serpentes, Reptiles) collection of the Museu Paraense Emílio Goeldi, Pará, Brazil.

BACKGROUND: We present a dataset with information from the snake collection of the Museu Paraense Emílio Goeldi, known as the "Ophidia Collection". This collection currently has 26,728 specimens of snakes, including 9 families, 66 genera and 220 species. For the most part, it represents material from the Amazon Region. Specimens are preserved mostly in wet (alcohol) preparation, with some samples preserved in dry form, as is the case of the shells and skeletons of turtles. The dataset is now available for public consultation on the Global Biodiversity Information Facility portal (https://doi.org/10.15468/lt0wet). NEW INFORMATION: The Herpetological collection of Museu Paraense Emílio Goeldi comprises the largest collection of its kind in the Amazon region with about 100,000 specimens of amphibians and reptiles (chelonians, alligators, lizards, snakes and amphisbaenians). This collection currently has 26,728 specimens of snakes, including 9 families, 66 genera and 220 species, some of which are endemic to the Amazon rainforest region. The Museu Paraense Emílio Goeldi is the second oldest institution of science in Brazil in activity, founded in 1866.

Can Vertical Integration Reduce Hospital Readmissions? A Difference-in-Differences Approach.

BACKGROUND: Vertical integration is expected to improve communication and coordination between inpatient care and care after discharge. Despite being used across health systems worldwide, evidence about its impact on readmissions is sparse and contradictory. OBJECTIVE: To assess the impact of vertical integration on hospital readmissions. RESEARCH DESIGN, SUBJECTS, AND MEASURES: Using difference-in-differences we compared readmissions before and after vertical integration in 6 Portuguese hospitals for years 2004-2013. A control group with 6 similar hospitals not integrated was utilized. Considered outcome was 30-day unplanned readmission. We used logistic regression at the admission level and accounted for patients' risk factors using claims data. Analyses for each hospital and selected conditions were also run. RESULTS: Our results suggest that readmissions decreased overall after vertical integration [odds ratio (OR)=0.900; 95% confidence interval (CI), 0.812-0.997]. Hospital analysis indicated that there was no impact for 2 hospitals (OR=0.960; 95% CI, 0.848-1.087 and OR=0.944; 95% CI, 0.857-1.038), and a positive effect in 4 hospitals (greatest effect: OR=0.811; 95% CI, 0.736-0.894). A positive evolution was observed for a limited number of conditions, with better results for diabetes with complications (OR=0.689; 95% CI, 0.525-0.904), but no impact regarding congestive heart failure (OR=1.067; 95% CI, 0.827-1.377). CONCLUSIONS: Merging acute and primary care providers was associated with reduced readmissions, even though improvements were not found for all institutions or condition-specific groups. There are still challenges to be addressed regarding the success of vertical integration in reducing 30-day hospital readmissions.

The impact of multiple chronic diseases on hospitalizations for ambulatory care sensitive conditions.

BACKGROUND: The high financial burden of avoidable hospitalizations has led to an increase of the study of hospitalizations for ambulatory care sensitive conditions (ACSC). There is limited information on the impact of secondary diagnoses on these hospitalizations, although patients' social and demographic characteristics, as well as the coexistence of multiple diseases are often identified in the literature as risk factors for avoidable hospitalizations. This study explores the impact of chronic conditions on the likelihood of hospitalizations for ACSC. METHODS: Data were extracted from the Portuguese hospital discharge database. Avoidable hospitalizations were identified according to the Canadian Institute for Healthcare Information, and chronic conditions were identified according to criteria set by the Agency for Healthcare Research and Quality. A retrospective study analysing all patients hospitalized for an ACSC and all patients hospitalized for non-ACSC was made, using multiple logistic regression models to identify the impact of chronic conditions on the risk of admission. RESULTS: The risk of an avoidable hospitalization increases by a factor of 1.35 (95 % CI [1.34;1.35]) for each additional chronic condition, and 1.55 (95 % CI [1.55;1.56]) for each additional body system affected. The respiratory and circulatory systems have the most impact on the risk of ACSC, increasing the risk by 8.72 (95 % CI [8.58;8.86]) and 3.01 (95 % CI [2.95;3.06]), respectively. CONCLUSIONS: The number of chronic conditions and the body systems affected increase the risk of hospital admissions for ACSC.

[Characterization and Evolution of Avoidable Admissions in Portugal: The Impact of Two Methodologic Approaches]. / Caracterização e Evolução dos Internamentos Evitáveis em Portugal: Impacto de Duas Abordagens Metodológicas.

INTRODUCTION: The aim of this study is to evaluate the health systems performance through the avoidable hospital admissions, once these have gained international relevance. We used two different methods to identify the admissions for Ambulatory Care Sensitive Conditions, describing the Portuguese reality and evolution. MATERIAL AND METHODS: Over 12 million hospitalizations were analyzed between 2000 and 2012 using the national hospital discharge databases. We used two different methodologies to identify the hospitalizations for Ambulatory Care Sensitive Conditions, determining their concordance. We also estimated potential improvement scenarios. RESULTS: In 2012, 4.4% and 32.4% of the hospitalizations for medical causes were avoidable according to the Canadian and Spanish methodologies respectively. The hospitalizations are more frequent in children and the elderly. The most frequent causes vary according to the age group and methodology. During the analyzed period the rate of admissions has dropped 20% according to the Canadian methodology and increased 16% according to the Spanish methodology. There are regional clusters of performance under and above the national average. The concordance between methodologies is low. The improvement scenarios estimated possible reductions between 20.3% and 53.5% of the hospitalizations. DISCUSSION: The avoidable admissions assume a relevant volume in Portugal. Although in theory they are avoidable their complete elimination is a practical impossibility. Their study, however, allows the evaluation and results motorization enabling to establish intervention priorities. CONCLUSION: To have a precise characterization of the avoidable admissions in Portugal it is necessary to achieve consensus on the identification methodology.

Introdução: O objectivo deste estudo é avaliar a performance dos sistemas de saúde através dos internamentos evitáveis, dado que estes têm vindo a ganhar importância a nível internacional. Foram utilizadas duas metodologias distintas para a identificação dos internamentos por Ambulatory Care Sensitive Conditions, fazendo uma descrição da realidade e a evolução destes em Portugal. Material e Métodos: Analisámos mais de 12 milhões de internamentos entre 2000 e 2012, utilizando as bases de dados de resumos de alta nacionais. Utilizaram-se duas metodologias de identificação das Ambulatory Care Sensitive Conditions, determinando a sua concordância. Calculámos cenários de melhoria potencial. Resultados: Em 2012, 4,4% e 32,5% dos internamentos por causas médicas seriam evitáveis segundo a metodologia canadiana e espanhola respectivamente. Os internamentos são mais frequentes nas crianças e nos idosos, divergindo as suas causas de acordo com o grupo etário e a metodologia utilizada. A taxa de internamentos no período em análise diminuiu 20% segundo a metodologia canadiana e aumentou 16% segundo a espanhola. Existem agregados regionais de performance acima e abaixo da média nacional. A concord ncia entre as duas metodologias é baixa. Estimaram-se reduções potenciais entre 20,3% e 53,5% dos internamentos.Discussão: Os internamentos evitáveis assumem um volume considerável em Portugal. Apesar de em teoria serem evitáveis a sua eliminação por completo não é uma possibilidade prática, no entanto, o seu estudo possibilita a avaliação e monitorização de resultados e o estabelecimento de prioridades de intervenção. Conclusão: Para uma caracterização mais precisa dos internamentos evitáveis é necessário consensualizar em Portugal a metodologia para a sua identificação.