Chronic pain and continuity of analgesic treatment during the COVID-19 pandemic.

INTRODUCTION: Chronic pain can trigger both physical and mental health complications. During the COVID-19 pandemic, patients with chronic diseases have had reduced access to some medications. OBJECTIVE: To determine the pharmacological management of patients with chronic pain and its continuity during the COVID-19 pandemic. METHODS: This was a retrospective longitudinal study of the continuity of analgesic use in patients with chronic pain between September 1, 2019 and February 28, 2021 based on a drug dispensing database. Survival analysis was performed until the discontinuation of chronic analgesics. RESULTS: A total of 12,701 patients who were being treated for chronic pain were identified. Their median age was 70.3 years, and 74.4% were women. The pain of rheumatological origin was the most frequent etiology (46.1%); the most used medications were nonopioid analgesics (78.9%), pain modulators (24.8%) and opioid analgesics (23.3%). A total of 76.1% of the patients experienced interruptions in their management during the study period. The median time to the first interruption of treatment was 5.0 months (95% CI: 4.8-5.2). Those who were treated for oncological pain experienced a greater number of interruptions in their management. CONCLUSIONS: The pharmacological management of patients with chronic pain is heterogeneous, and this real-world study showed that a high proportion of patients experienced an interruption of pain management during the 12 months following the onset of the COVID-19 pandemic.

A comparative study of adult and adolescent maternal care continuum following community-oriented interventions in Cambodia, Guatemala, Kenya, and Zambia.

BACKGROUND: The coverage for reproductive care continuum is a growing concern for communities in low- income economies. Adolescents (15-19 years) are often at higher odds of maternal morbidity and mortality due to other underlying factors including biological immaturity, social, and economic differences. The aim of the study was to examine a) differences in care-seeking and continuum of care (4 antenatal care (ANC4+), skilled birth attendance (SBA) and postnatal care (PNC) within 24h) between adult (20-49 Years) and adolescents and b) the effect of multilevel community-oriented interventions on adolescent and adult reproductive care-seeking in Cambodia, Guatemala, Kenya, and Zambia using a quasi-experimental study design. METHODS: In each country, communities in two districts/sub-districts received timed community health worker (CHW) household health promotion and social accountability interventions with community scorecards. Two matched districts/sub-districts were selected for comparison and received routine healthcare services. RESULTS: Results from the final evaluation showed that there were no significant differences in the care continuum for adolescents and adults except for Kenya (26.1% vs 18.8%, p<0.05). SBA was significantly higher for adolescents compared to adult women for Guatemala (64% vs 55.5%, p<0.05). Adolescents in the intervention sites showed significantly higher ANC utilization for Kenya (95.3% vs 84.8%, p<0.01) and Zambia (87% vs 72.7%, p<0.05), ANC4 for Cambodia (83.7% vs 43.2%, p<0.001) and Kenya (65.9% vs 48.1%, p<0.05), SBA for Cambodia (100% vs 88.9%, p<0.05), early PNC for Cambodia (91.8% vs 72.8%, p<0.01) and Zambia (56.5% vs 16.9%, p<0.001) compared to the comparison sites. However, the findings from Guatemala illustrated significantly lower care continuum for intervention sites (aOR:0.34, 95% CI 0.28-0.42, p<0.001). The study provides some evidence on the potential of multilevel community-oriented interventions to improve adolescent healthcare seeking in rural contexts. The predictors of care continuum varied across countries, indicating the importance of contextual factors in designing interventions.

Impact of the COVID-19 pandemic on health care activities at a Uruguayan mastology unit.

PURPOSE: Health emergency due to COVID-19 started in Uruguay on March 13, 2020; our mastology unit tried to ensure adequate oncological care, and protect patients from the virus infection and complications. OBJECTIVE: To assess the health care activities in the "peak" of the pandemic during 3 months. MATERIALS AND METHODS: we collected data from the electronic health record. RESULTS: There were a total of 293 medical appointments from 131 patients (221 face-to-face), that decreased by 16.7% compared to the same period in 2019 (352 appointments). The medical appointments were scheduled to evaluate the continuity of systemic treatment or modifications (95 patients; 72.5%), follow-up (17; 12.9%), first-time consultation (12; 9.1%), and assess paraclinical studies (7; 5.3%). The patients were on hormone therapy (81 patients; 74%), chemotherapy (CT) (21; 19%), and anti-HER2 therapies (9; 8%). New twenty treatments were initiated. Of the 14 patients that were on adjuvant/neoadjuvant CT, 9 (64.3%) continued with the same regimen with the addition of prophylactic granulocyte-colony-stimulating factors (G-CSF), and 5 (35.7%), who were receiving weekly paclitaxel, continued the treatment with no changes. Of the seven patients that were on palliative CT, 2 (28.5%) continued the treatment with the addition of G-CSF, 3 (42.8%) continued with weekly capecitabine or paclitaxel with no treatment changes, and 2 (28.5%) changed their treatment regimen (a less myelosuppressive regimen was selected for one and due to progression of the disease in the other patient). The ninety patients who were receiving adjuvant, neoadjuvant, or palliative criteria hormone therapy and/or anti-HER2 therapies, continued the treatment with no changes. CONCLUSIONS: The evidence suggests that, although medical appointments decreased by approximately 17%, we could maintain healthcare activities, continued most of the treatments while the most modified was CT with G-CSF to avoid myelosuppression.

A COVID-19 pandemic-specific, structured care process for peritoneal dialysis patients facilitated by telemedicine: Therapy continuity, prevention, and complications management.

Coronavirus disease 2019 (COVID-19) has been declared a pandemic. Peritoneal dialysis (PD), being a home therapy, allows for physical distancing measures and movement restrictions. In order to prevent COVID-19 contagioun among the Dominican Republic National Health System PD program patients, a follow-up virtual protocol for this group was developed. The aim of this study is to outline the protocol established by the PD program's healthcare team using telemedicine in order to avoid COVID-19 transmission and to report initial results and outcomes of this initiative. This is an observational prospective longitudinal study with 946 patients being treated in seven centers distributed throughout the country between April 1 and June 30. The protocol was implemented focusing on the patient follow-up; risk mitigation data were registered and collected from electronic records. During the follow-up period, 95 catheters were implanted, 64 patients initiated PD, and the remaining were in training. A total of 9532 consultations were given by the different team specialists, with 8720 (91%) virtual and 812 (9%) face-to-face consultations. The transfer rate to hemodialysis was 0.29%, whereas the peritonitis rate was 0.11 episode per patient/year. Eighteen adults tested positive for COVID-19. The implementation of the protocol and telemedicine utilization have ensured follow-up and monitoring, preserved therapy, controlled complications, and PD lives protected.

Evaluación de la continuidad del cuidado brindado por médicos de atención primaria en un seguro de salud de un hospital universitario privado de Argentina / Evaluation of the continuity of care provided by primary care physicians in a private university hospital's health insurance scheme in Argentina

Antecedentes. La continuidad del cuidado (CoC) suele describir en qué medida los pacientes ven al mismo profesional a lo largo del tiempo. Constituye un elemento necesario para garantizar la longitudinalidad en la atención, elemento clave dela atención primaria y de la medicina familiar en particular, entendido como el cuidado centrado en la persona a lo largo del tiempo, independientemente del tipo de problema consultado. Esta ha sido vinculada con una serie de beneficios para los pacientes y algunos indicadores duros de utilización de servicios de salud, por ejemplo visitas a la central de emergencias(CE), internaciones hospitalarias y mortalidad. En Argentina y América Latina no habíamos podido identificar estudios que dieran cuenta del nivel local de CoC o de su impacto en la utilización de los servicios de salud. Objetivo. Cuantificar los niveles de CoC de los afiliados de un Seguro de Salud de un Hospital Universitario Privado y describir su asociación con la utilización de servicios de salud, tales como consultas a la CE e internaciones hospitalarias. Métodos. Estudio observacional, descriptivo, de cohorte retrospectiva; realizado sobre la totalidad de afiliados que hubieran realizado al menos dos consultas programadas con un médico de atención primaria entre 2015 y 2016.Las mediciones principales consistieron dos indicadores: el índice del proveedor usual de cuidados y el índice de continuidad del cuidado (UPC y COC, respectivamente, por sus iniciales en inglés) -cuyos valores oscilan entre 0 y 1, y se interpretan como: el paciente siempre fue atendido por diferentes médicos vs siempre por el mismo médico-y el recuento de visitas a la CE e internaciones hospitalarias. Resultados. Fueron identificados 112.062 pacientes con una mediana de edad de 59 (P5-P95;4 a 87) años. Las medianas(P5-P95) de los indicadores de continuidad, UPC y COC, fueron 0,66 (0,25 a 1) y 0,33 (0,04 a 1), respectivamente. Se observó una asociación inversa y estadísticamente significativa entre los indicadores de CoC y la cantidad de visitas a la CE, evidenciada por una razón de incidencia decreciente de consultas contra quintilos crecientes de COC (tomando como referencia el quintilo más bajo de continuidad). Esta asociación no pudo demostrarse para las internaciones. Conclusiones. Los niveles de CoC alcanzados y su impacto en la utilización de servicios de salud reflejan valores semejantes a los de otros estudios publicados fuera de nuestra región y podrían aportar elementos útiles para delinear estrategias tendientes a la mejora de la calidad de la atención médica. (AU)

Background. Continuity of care (CoC) usually describes the extent to which patients see the same professional over time. It is a necessary element to ensure continuity of care, a key element of primary care and family medicine, in particular, understood as person-centred care over time, regardless of the type of problem consulted. It has been linked to a series of benefits for patients as well as to hard indicators of health services utilization (e.g. emergency room [ER] visits, hospitalizations) and mortality. In Argentina and Latin America, we have not been able to identify studies that account for the local level of CoC and its impact. Objective. To quantify the CoC levels among members of a private university hospital's health insurance scheme and to describe its association with the use of health services, such as ER visits and hospitalizations. Methods. Observational, descriptive, retrospective cohort study; conducted on the total number of members who hadmade at least two schedurivled consultations with a primary care physician between 2015 and 2016.The main outcomes were two indicators: the usual provider continuity index and the continuity of care index (UPC and COC, respectively) -both range between 0 and 1, and are interpreted as: the patient was always treated by different doctorsvs. always by the same doctor- and the number of visits to the ER and hospitalizations. Results. A total of 112,062 patients with a median age of 59 (P5-P95, 4 to 87) years were identified. The median (P5-P95) of the continuity indicators, UPC and COC, was 0.66 (0.25 to 1) and 0.33 (0.04 to 1), respectively. A significant inverse association was observed between the CoC indicators and the number of ER visits, evidenced by adecreasing incidence rate of consultations versus increasing quintiles of CoC (taking the lowest quintile of continuity as a reference). This association was not observed for hospitalizations. Conclusions. The levels of CoC reached and their impact on the use of health services reflect similar values to those of other studies published outside our region and could provide useful elements for outlining strategies aimed at improvingthe quality of medical care. (AU)

Continuidad del cuidado / Continuity of care

El concepto de continuidad del cuidado (CoC) suele utilizarse para describir en qué medida los pacientes ven al mismo profesional a lo largo del tiempo, aunque más específicamente es un atributo o característica del proceso de atención de salud de un individuo en el que la calidad de la conexión y retroalimentación de los eventos que se suceden influyen en la experiencia final de sentirse cuidado. La CoC abarca diferentes dominios conceptuales: la continuidad de la información, de la relación y del manejo. Se han utilizado diferentes instrumentos de medición que pueden agruparse en herramientas elaboradas a partir de reportes de pacientes (como por ej., encuestas) o a partir de datos administrativos (como los indicadores de prestador usual de cuidados o el indicador de Bice y Boxerman). Existen también investigaciones que evaluaron el impacto sanitario de la CoC. Si bien muchas de ellas muestran gran heterogeneidad en cuanto a los indicadores y los desenlaces utilizados, se observa una tendencia clara que parece indicar que a mayor nivel de continuidad del cuidado, mejores resultados en salud. (AU)

The concept of continuity of care (CoC) is often used to describe the extent to which patients see the same professional over time, but more specifically it is an attribute or characteristic of an individual's health care process in which the quality of the connection and feedback of the events that follow influences the final experience of feeling cared for. CoC encompasses different conceptual domains: continuity of information, relationship, and management. Different measurement instruments have been used, which can be grouped into tools developed from patient reports (e.g. surveys) or from administrative data (e.g. usual caregiver indicators or the Bice & Boxerman indicator). There is also research that has assessed the health impact of CoC. While many of them show great heterogeneity in terms of the indicators and outcomes used, there is a clear trend that seems to indicate that the higher the level of continuity ofcare, the better the health outcomes. (AU)

El desempeño del primer nivel y su relación con las hospitalizaciones evitables / The primary care performance and its relationship with preventable hospitalizations

INTRODUCCIÓN. El enfoque de atención primaria en el diseño de servicios de salud sigue siendo importante. La coordinación asistencial y la continuidad de la atención son ejes fundamentales para el abordaje de las enfermedades crónicas no transmisibles como la diabetes mellitus, que ha sido catalogada como enfermedad susceptible de cuidados ambulatorios. Las tasas de hospitalización elevadas por este tipo de condiciones reflejan una atención ambulatoria deficiente e inadecuada para el problema de salud estudiado, lo que implica que la población no accedió a la atención, o que esta no es resolutiva. MATERIALES Y MÉTODOS. Se analizaron todas las consultas de emergencia, en 12 meses en un hospital de Quito, se buscaron consultas externas de pacientes en todos los establecimientos de primer nivel del MSP antes de la consulta por emergencia, desde el 1 de enero de 2015 hasta un día antes de la consulta por emergencia. RESULTADOS. De 41 pacientes atendidos con diagnóstico de enfermedades evitables 58% eran mujeres, 43% (18) requirió hospitalización. El promedio de días de hospitalización fue 6,51, con una dispersión de 13,0; el de consultas externas previo a la emergencia fue 3,07, con máximo 22 consultas. Los hospitalizados tuvieron, en promedio, 5,05 consultas externas antes de la emergencia y hospitalización, aproximadamente 4 más que el promedio (0,95) de los pacientes no hospitalizados. DISCUSIÓN. las elevadas tasas de hospitalización podrían reflejar una atención primaria deficiente, lo que implica que la población no accedió a la atención, sin embargo, habría que analizar la gravedad de los pacientes.

INTRODUCTION. Primary care services are important for the delivery of comprehensive health services. The coordination and continuity of care are the main characteristics to approach non-communicable diseases like diabetes mellitus, which has been classified as ambulatory care sensitive condition. The high hospitalization rate might reveal poor and inadequate out-patient care, implying that the population did not access care, or that care was not effective. MATERIALS AND METHODS. All emergency consultations within 12 months in one hospital in Quito were analyzed according to their ICD-10 codes. They were compared with the consultations at the first level of care facilities of the Ministry of Public Health, from January 1st, 2015 until one day before the emergency consultation. RESULTS. Of 41 patients who attended with a diagnosis of preventable diseases 58% were wo-men, 43% (18) required hospitalization. The average number of days of hospitalization was 6.51, with a dispersion of 13.0; the number of external consultations prior to the emergency was 3.07, with a maximum of 22 consultations. The hospitalized patients had, on average, 5.05 outpatient visits before the emergency and hospitalization, approximately 4 more than the average (0.95) of the non-hospitalized patients. DISCUSSION. The high hospitalization rate, due to this condition, might reveal poor and inadequate ambulatory care, nevertheless it is necessary to analyze the severity of the cases in the studs.

Care transition from hospital to home: cancer patients' perspective.

OBJECTIVES: The present database contains information on sociodemographic and clinical data as well as data from the Care Transition Measure (CTM 15-Brazil) of cancer patients undergoing clinical or surgical treatment. Data collection was carried out 7 to 30 days after patients' hospital discharge from June to August 2019. Understanding these data can contribute to improving quality of care transitions and avoiding hospital readmissions. DATA DESCRIPTION: This data set encompasses 213 cancer patients characterized by the follow variables: gender, age range, place of residence, race, marital status, schooling, paid work activity, type of treatment, cancer staging, metastasis, comorbidities, main complaint, main complaint grouped as, continuing medication, diagnosis, diagnosis grouped as, cancer type, year of diagnosis, oncology treatment, first hospitalization, readmission in the last 30 days, number of hospitalizations in the last 30 days, readmission in the last 6 months, number of hospitalizations in the last 6 months, readmission in the last year, number of hospitalizations in the last year and the questions 1-15 from CTM 15-Brazil.

Returning to care after incarceration with HIV: the French Guianese experience.

BACKGROUND: HIV prevalence in correctional facilities may be 2 to 10 times higher than in the general adult population. Antiretroviral therapy (ART) interruption is frequent after an incarceration. This, in combination with post-release high-risk behaviors, may have detrimental consequences on the epidemic. Although return to care after release from correctional facilities has been described in many North American settings, data from South America seemed scarce. French Guiana is the only French territory located in South America. In 2014, HIV prevalence was estimated at 1.2% among pregnant women and oscillated around 4% in the only correctional facility. METHOD: HIV-infected adults released from the French Guiana correctional facility between 2007 and 2013 were included in a retrospective cohort survey. The first objective was to describe the cascade of care in the 4 years following release. The secondary objectives were to describe contacts with care and to identify factors associated with return to HIV care, 1 year after release. RESULTS: We included 147 people, mostly males (81.6%). The median time before the first ambulatory consultation was 1.8 months. Within 1 year after release, 27.9% came for unscheduled emergency consultations, 22.4% were hospitalized. Within 4 years after release, 40.0-46.5% were in care, 22.4% archieved virological success. Being on ART when incarcerated was associated with HIV care (aIRR: 2.0, CI: 1.2-3.0), whereas being HIV-diagnosed during the last incarceration was associated with poor follow-up (aIRR: 0.3, CI: 0.1-0.9). CONCLUSION: The risk of HIV-follow-up interruption is high, after an incarceration with HIV. ART supply should be sufficient to cover the timespan following release, several months if possible. Those not on ART at the time of incarceration may require special attention, especially those newly HIV-diagnosed while in custody. Comprehensive programs are necessary to support ex-offenders to stay on ART after incarceration.

Timely care linkage of people living with HIV in a reference health service, Belo Horizonte, Minas Gerais. / Oportunidade de vinculação de pessoas vivendo com HIV em um serviço especializado de saúde, Belo Horizonte (MG).

INTRODUCTION: Linkage is a critical step in the ongoing care of human immunodeficiency virus (HIV/aids) infection and is essential for providing access to antiretroviral therapy, as well as comprehensive care. METHODOLOGY: Cross-sectional study on people living with HIV (PLHIV), aged ≥ 18 years old, linked between January and December 2015, in a referral service for outpatient and hospital care specialized in HIV/AIDS in Belo Horizonte, Minas Gerais. Linkage time was defined as the time from diagnosis to service linkage. Timely care linkage was considered when this time was ≤ 90 days. Data were collected through clinical records. A logistic regression analysis with a confidence interval of 95% (95%CI) was performed. RESULTS: Among 208 patients, most of them were males (77.8%) with a mean age of 39 years. About 45% presented AIDS-defining conditions at the moment of linkage. Linkage time presented a mean of 138 ± 397 days. And timely linkage occurred for 76.9% of the patients. The variables associated with timely care linkage were: age ≥ 48 years (odds ratio - OR = 8.50; 95%CI 1.53 - 47.28), currently working (OR = 3.69; 95%CI 1.33 - 10.25) at the time of linkage, and present CD4+ T lymphocyte count (CD4+ T) ≤ 200 cells/mm3 at the time of HIV diagnosis (OR = 4.84; 95%CI 1.54 - 15.18). There was an important proportion of timely care linkage among PLHIV, but with late diagnosis. CONCLUSION: Interventions should be targeted at younger people with higher CD4+ T lymphocyte counts, in order to better provide continuous HIV care.

INTRODUÇÃO: A vinculação é um passo fundamental para o cuidado contínuo da infecção pelo vírus da imunodeficiência humana (HIV/aids), sendo essencial para proporcionar o acesso à terapia antirretroviral, bem como ao cuidado integral. METODOLOGIA: Estudo transversal, com pessoas vivendo com HIV (PVHIV), idade ≥ 18 anos, vinculadas entre janeiro e dezembro de 2015, em um serviço de referência para assistência ambulatorial e hospitalar especializada em HIV/aids em Belo Horizonte (MG). O tempo de vinculação foi definido como o tempo do diagnóstico até a vinculação ao serviço. Considerou-se vinculação oportuna quando esse tempo foi menor ou igual a 90 dias. Os dados foram coletados por meio de prontuários clínicos. Realizou-se análise de regressão logística com intervalo de confiança de 95% (IC95%). RESULTADOS: Entre os 208 pacientes, a maioria era do sexo masculino (77,8%) com idade média de 39 anos. Cerca de 45% apresentaram condições definidoras de aids na vinculação. O tempo de vinculação apresentou média de 138 ± 397 dias, e a vinculação oportuna ocorreu para 76,9% dos pacientes. As variáveis associadas com a vinculação oportuna foram: ter idade ≥ 48 anos (odds ratio - OR = 8,50; IC95% 1,53 - 47,28), estar trabalhando (OR = 3,69; IC95% 1,33 - 10,25) no momento da vinculação e apresentar contagem de linfócitos T CD4 (LT CD4+) ≤ 200 células/mm3 no momento do diagnóstico de HIV (OR = 4,84; IC95% 1,54 - 15,18). Observou-se proporção importante de vinculação oportuna entre as PVHA, porém com diagnóstico tardio. CONCLUSÃO: Intervenções devem ser direcionadas para pessoas mais jovens e com maior contagem de LT CD4+, visando uma melhor prestação de cuidados contínuos em HIV.

Oportunidade de vinculação de pessoas vivendo com HIV em um serviço especializado de saúde, Belo Horizonte (MG) / Timely care linkage of people living with HIV in a reference health service, Belo Horizonte, Minas Gerais

RESUMO: Introdução: A vinculação é um passo fundamental para o cuidado contínuo da infecção pelo vírus da imunodeficiência humana (HIV/aids), sendo essencial para proporcionar o acesso à terapia antirretroviral, bem como ao cuidado integral. Metodologia: Estudo transversal, com pessoas vivendo com HIV (PVHIV), idade ≥ 18 anos, vinculadas entre janeiro e dezembro de 2015, em um serviço de referência para assistência ambulatorial e hospitalar especializada em HIV/aids em Belo Horizonte (MG). O tempo de vinculação foi definido como o tempo do diagnóstico até a vinculação ao serviço. Considerou-se vinculação oportuna quando esse tempo foi menor ou igual a 90 dias. Os dados foram coletados por meio de prontuários clínicos. Realizou-se análise de regressão logística com intervalo de confiança de 95% (IC95%). Resultados: Entre os 208 pacientes, a maioria era do sexo masculino (77,8%) com idade média de 39 anos. Cerca de 45% apresentaram condições definidoras de aids na vinculação. O tempo de vinculação apresentou média de 138 ± 397 dias, e a vinculação oportuna ocorreu para 76,9% dos pacientes. As variáveis associadas com a vinculação oportuna foram: ter idade ≥ 48 anos (odds ratio - OR = 8,50; IC95% 1,53 - 47,28), estar trabalhando (OR = 3,69; IC95% 1,33 - 10,25) no momento da vinculação e apresentar contagem de linfócitos T CD4 (LT CD4+) ≤ 200 células/mm3 no momento do diagnóstico de HIV (OR = 4,84; IC95% 1,54 - 15,18). Observou-se proporção importante de vinculação oportuna entre as PVHA, porém com diagnóstico tardio. Conclusão: Intervenções devem ser direcionadas para pessoas mais jovens e com maior contagem de LT CD4+, visando uma melhor prestação de cuidados contínuos em HIV.

ABSTRACT: Introduction: Linkage is a critical step in the ongoing care of human immunodeficiency virus (HIV/aids) infection and is essential for providing access to antiretroviral therapy, as well as comprehensive care. Methodology: Cross-sectional study on people living with HIV (PLHIV), aged ≥ 18 years old, linked between January and December 2015, in a referral service for outpatient and hospital care specialized in HIV/AIDS in Belo Horizonte, Minas Gerais. Linkage time was defined as the time from diagnosis to service linkage. Timely care linkage was considered when this time was ≤ 90 days. Data were collected through clinical records. A logistic regression analysis with a confidence interval of 95% (95%CI) was performed. Results: Among 208 patients, most of them were males (77.8%) with a mean age of 39 years. About 45% presented AIDS-defining conditions at the moment of linkage. Linkage time presented a mean of 138 ± 397 days. And timely linkage occurred for 76.9% of the patients. The variables associated with timely care linkage were: age ≥ 48 years (odds ratio - OR = 8.50; 95%CI 1.53 - 47.28), currently working (OR = 3.69; 95%CI 1.33 - 10.25) at the time of linkage, and present CD4+ T lymphocyte count (CD4+ T) ≤ 200 cells/mm3 at the time of HIV diagnosis (OR = 4.84; 95%CI 1.54 - 15.18). There was an important proportion of timely care linkage among PLHIV, but with late diagnosis. Conclusion: Interventions should be targeted at younger people with higher CD4+ T lymphocyte counts, in order to better provide continuous HIV care.

Care complexity in hospitalized elderly according to cognitive performance.

OBJECTIVE: to investigate possible differences in care complexity, functional performance and biopsychosocial and health system aspects among hospitalized elderly with or without cognitive decline. METHOD: quantitative, cross-sectional and analytical study in which was used the INTERMED method and cognitive and functional screening scales. We investigated 384 elderly patients admitted to a medical and surgical clinic of a University Hospital located in São Paulo/SP. RESULTS: cognitive decline was present in 40.1% of the sample, most of them were longer-lived elderly individuals with less schooling and income, more dependent in activities of daily living and had greater vulnerability in different domains of INTERMED. After adjustments, the elderly with cognitive decline presented greater vulnerability in the psychological domain. CONCLUSION: the relationship between cognitive decline and psychological vulnerability highlights the need to adopt long-term care based on involvement of the family, health team and different services, thereby maximizing the quality of care.

Continuity of care and delivery of diabetes and hypertensive care among regular users of primary care services in Chile: a cross-sectional study.

OBJECTIVES: Explore factors related to continuity of care and its association with diabetes and hypertensive care, and disease control. DESIGN: Cross-sectional study. SETTING: Data from the Chilean Health National Survey 2009-2010. PARTICIPANTS: Regular users of primary care services aged 15 or older. PRIMARY AND SECONDARY OUTCOME MEASURES: Proportion of hypertensive and diabetic patients with a blood pressure <140/90 mm Hg and HbA1c<7.0% respectively, self-report of diagnosis, treatment and recent foot and ophthalmological exams. Associations between continuity of care, sociodemographic characteristics, and primary and secondary outcomes were explored using logistic regression. RESULTS: 3887 primary care service users were included. 14.7% recognised a usual GP, 82.3% of them knew their name. Continuity of care was positively associated with age >65 years (OR 4.81, 95% CI 3.16 to 7.32), being female (OR 1.66, 95% CI 1.34 to 2.05), retired (OR 2.22, 95% CI 1.75 to 2.83), obese (OR 1.66, 95% CI 1.29 to 2.14), high cardiovascular risk (OR 2.98, 95% CI 2.13 to 4.17) and widowed (OR 1.50, 95% CI 1.13 to 1.99), and negatively associated with educational level (8-12 vs <8 years OR 0.79, 95% CI 0.64 to 0.97), smoking (OR 0.65, 95% CI 0.52 to 0.82) and physical activity (OR 0.76, 95% CI 0.61 to 0.95). Continuity of care was associated with diagnosis awareness (OR 2.83, 95% CI 1.21 to 6.63), pharmacological treatment (OR 2.04, 95% CI 1.15 to 3.63) and a recent foot (OR 3.17, 95% CI 1.84 to 5.45) and ophthalmological exam (OR 3.20, 95% CI 1.66 to 6.18) in diabetic but not in hypertensive patients. CONCLUSIONS: Continuity of care was associated with higher odds of having a recent foot and ophthalmological exam in patients with diabetes, but not with better diseases control. Findings suggest patients with chronic conditions have better continuity of care access.

The QualiRede intervention: improving the performance of care continuum in HIV, congenital syphilis, and hepatitis C in health regions.

INTRODUCTION: Care continuum models have supported recent strategies against sexually transmitted diseases, such as HIV and Hepatitis C (HCV). METHODS: HIV, HCV, and congenital syphilis care continuum models were developed, including all stages of care, from promotion/prevention to clinical control/cure. The models supported the intervention QualiRede, developed by a University-Brazilian National Health System (SUS) partnership focused on managers and other professionals from six priority health regions in São Paulo and Santa Catarina. Indicators were selected for each stage of the care continuum from the SUS information systems and from the Qualiaids and QualiAB facility's process evaluation questionnaires. The indicators acted as the technical basis of two workshops with professionals and managers in each region: the first one to identify problems and to create a Regional Technical Group; and the second one to design action plans for improving regional performance. RESULTS: The indicators are available at www.qualirede.org. The workshops took place in the regions of Alto Tietê, Baixada Santista, Grande ABC, and Registro (São Paulo) and of Foz do Rio Itajaí (Santa Catarina), which resulted in regional action plans in São Paulo, but not in Santa Catarina. A lack of awareness was observed regarding the new HIV and HCV protocols, as well as an incipient use of indicators in routine practices. CONCLUSION: Improving the performance of the care continuum requires appropriation of performance indicators and coordination of care flows at local, regional, and state levels of management.

Avaliação clínica e imunológica dos receptores de transplante renal / Clinical and immunological assessment of renal transplant recipients / Evaluación clínica e inmunológica de los receptores de trasplante renal

Objetivo: Avaliar as características clínicas e imunológica dos receptores de transplante renal. Métodos: estudo documental e retrospectivo, realizado em um Ambulatório do Hospital Geral de Fortaleza, Fortaleza, Ceará, Brasil, com pacientes internados no período de junho de 2012 a junho de 2014. A amostra foi composta por 300 pacientes submetidos ao transplante renal. As variáveis preditoras de interesse, foram subdivididas em: características prétransplante, características pós-transplante e características imunológicas. Utilizou-se testes de Pearson e Spearman para avaliar correlação entre variáveis. Resultados: Houve predomínio de pacientes do sexo masculino (65%), com faixa etária entre 44 e 56 anos (31,4%). Demonstrou-se relação estatisticamente significante entre o DSA e a disfunção do enxerto (p<0,04), Rejeição celular o Painel Reativo classe I (p< 0,05), o tempo de internação e a disfunção do enxerto (p<0,001) e entre o entre o HLA e o MISMATCH. Conclusão: Aponta-se a necessidade de um acompanhamento crítico e individualizado do paciente transplantado por parte dos profissionais para garantir o sucesso do transplante a longo prazo

Objective: The study's purpose has been to assess both clinical and immunological characteristics of renal transplant recipients. Methods: It is a documentary and retrospective study that was performed at the renal transplantation ambulatory from the Hospital Geral de Fortaleza (HGF), Fortaleza city, Ceará State, with patients hospitalized from June 2012 to June 2014. The sample consisted of 300 patients submitted to renal transplantation. The predictive variables of interest were subdivided in the following categories: pre-transplant characteristics, post-transplant characteristics and immunological characteristics. Pearson and Spearman tests were used to evaluate the correlation between variables. Results: There was a predominance of male patients (65%), with ages ranging from 44 to 56 years (31.4%). A statistically significant relationship was found between the Donor-Specific Antibody and Delayed Graft Function (p<0.04), Cellular Rejection and PanelReactive Antibody class I (p<0.05), duration of hospitalization and Delayed Graft Function (p<0.001) and also between the Human Leukocyte Antigen and MISMATCH. Conclusion: It is pointed out the need for a critical and individualized follow-up of the transplanted patient by the professionals to guarantee the long-term transplantation success

Objetivo: Evaluar las características clínicas e inmunológicas de lós receptores de trasplante renal. Métodos: estudio documental y retrospectivo realizado en una clínica del Hospital General de Fortaleza, Fortaleza, Ceará, Brasil, con pacientes ingresados desde junio de 2012 a junio de 2014. La muestra fue de 300 pacientes sometidos a trasplante de riñón. Las variables predictoras de interés, fueron subdivididas en: características pretrasplante, características post-transplante y características inmunológicas. Se utilizaron pruebas de Pearson y Spearman para evaluar la correlación entre variables. Resultados: Hubo un predominio de pacientes del sexo masculino (65%), con edades comprendidas entre 44 y 56 años (31,4%). Se demostró una relación estadísticamente significativa entre el DSA y la disfunción del injerto (p <0,04), el rechazo celular del panel reactivo clase I (p <0,05), el tiempo de internación y la disfunción del injerto (p <0,001) y entre el HLA y el MISMATCH. Conclusión: Se apunta la necesidad de un acompañamiento crítico e individualizado del paciente trasplantado por parte de los profesionales para garantizar el éxito del trasplante a largo plazo

[Tuberculosis in indigenous children and adolescents in Brazil: factors associated with death and treatment dropout]. / Tuberculose entre crianças e adolescentes indígenas no Brasil: fatores associados ao óbito e ao abandono do tratamento.

The study aimed to describe clinical and sociodemographic characteristics, estimate incidence, and analyze factors associated with dropout and death during treatment of TB cases reported in indigenous children and adolescents in Brazil from 2006 to 2016. A historical case series was performed on incidence according to age bracket and major geographic region, and multinomial logistic regression was used to explain factors associated with treatment dropout and death. Of the 2,096 reported cases, 88.2% evolved to cure, 7.2% dropped out of treatment, and 4.6% evolved to death. There was a predominance of cases in boys 15-19 years of age and a higher proportion of deaths (55.7%) in children < 4 years. Considering indigenous children and adolescents with TB in Brazil as a whole, mean incidence was 49.1/100,000, ranging from 21.5/100,000 to 97.6/100,000 in the Northeast and Central, respectively. Cases with insufficient and irregular follow-up showed higher odds of dropout (OR = 11.1; 95%CI: 5.2-24.8/OR = 4.4; 95%CI: 1.9-10.3) and death (OR = 20.3; 95%CI: 4.9-84.9/OR = 5.1; 95%CI: 1.2-22.7). Cases in retreatment (OR = 2.4; 95%CI: 2.08-8.55) and with HIV coinfection (OR = 8.2; 95%CI: 2.2-30.9) were also associated with dropout. Extrapulmonary (OR = 1.8; 95%CI: 1.1-3.3) and mixed clinical forms (OR = 5.6; 95%CI: 2.8-11.4), age < 4 years (OR = 3.1; 95%CI: 1.5-6.4), and cases from the North (OR = 2.8; 95%CI: 1.1-7.1) and Central (OR = 2.8; 95%CI: 1.1-7.0) were associated with death. TB control in indigenous children and adolescents cannot be achieved without investments in research and development and without reducing social inequalities.

O objetivo deste estudo foi descrever características clínicas e sociodemográficas, estimar a incidência da tuberculose (TB), além de analisar fatores associados ao abandono e ao óbito na vigência do tratamento dos casos de TB notificados entre crianças e adolescentes indígenas, no Brasil, entre 2006-2016. Realizou-se análise da série histórica de incidência, segundo faixa etária e macrorregião e utilizou-se regressão logística multinomial para elucidar fatores associados ao abandono e ao óbito. Do total de 2.096 casos notificados, 88,2% tiveram cura, 7,2% abandonaram o tratamento e 4,6% evoluíram para óbito. Houve predomínio de casos em meninos de 15-19 anos e maior proporção de óbitos (55,7%) em < 4 anos. Considerando o conjunto de crianças e adolescentes indígenas com TB no Brasil, a incidência média foi 49,1/100 mil, variando de 21,5/100 mil a 97,6/100 mil nas regiões Nordeste e Centro-oeste, respectivamente. Os casos com acompanhamento insuficiente e regular tiveram maiores chances de abandono (OR = 11,1; IC95%: 5,2-24,8/OR = 4,4; IC95%: 1,9-10,3) e óbito (OR = 20,3; IC95%: 4,9-84,9/OR = 5,1; IC95%: 1,2-22,7). Os casos em retratamento (OR = 2,4; IC95%: 2,08-8,55) e com anti-HIV positivo (OR = 8,2; IC95%: 2,2-30,9) também mostraram-se associados ao abandono. As formas clínicas extrapulmonar (OR = 1,8; IC95%: 1,1-3,3) e mista (OR = 5,6; IC95%: 2,8-11,4), os casos em < 4 anos (OR = 3,1; IC95%: 1,5-6,4) e os casos provenientes das regiões Norte (OR = 2,8; IC95%: 1,1-7,1) e Centro-oeste (OR = 2,8; IC95%: 1,1-7,0) mostraram-se associados ao óbito. Acreditamos que o controle da TB em crianças e adolescentes indígenas não poderá ser alcançado sem investimentos em pesquisa e desenvolvimento e sem a redução das desigualdades sociais.

El objetivo de este estudio fue describir características clínicas y sociodemográficas, estimar la incidencia de la tuberculosis (TB), además de analizar factores asociados al abandono y al óbito en la vigencia del tratamiento de los casos de TB, notificados entre niños y adolescentes indígenas, en Brasil entre 2006-2016. Se realizó un análisis de la serie histórica de incidencia, según la franja de edad y macrorregión y se utilizó la regresión logística multinomial para elucidar factores asociados al abandono y al óbito. Del total de 2.096 casos notificados, un 88,2% tuvieron cura, un 7,2% abandonaron el tratamiento y un 4,6% evolucionaron hacia óbito. Hubo un predominio de casos en chicos de 15-19 años y mayor proporción de óbitos (55,7%) en < 4 años. Considerando el conjunto de niños y adolescentes indígenas con TB en Brasil, la incidencia media fue 49,1/100.000, variando de 21,5/100.000 a 97,6/100.000 en las regiones Nordeste y Centro-oeste, respectivamente. Los casos con un seguimiento insuficiente y regular tuvieron mayores oportunidades de abandono (OR = 11,1; IC95%: 5,2-24,8/OR = 4,4; IC95%: 1,9-10,3) y óbito (OR = 20,3; IC95%: 4,9-84,9/OR = 5,1; IC95%: 1,2-22,7). Los casos de retorno al tratamiento (OR = 2,4; IC95%: 2,08-8,55) y con anti-VIH positivo (OR = 8,2; IC95%: 2,2-30,9) también se mostraron asociados al abandono. Las formas clínicas extrapulmonares (OR = 1,8; IC95%: 1,1-3,3) y mixta (OR = 5,6; IC95%: 2,8-11,4), los casos en < 4 años (OR = 3,1; IC95%: 1,5-6,4) y los casos procedentes de las regiones Norte (OR = 2,8; IC95%: 1,1-7,1) y Centro-oeste (OR = 2,8; IC95%: 1,1-7,0) se mostraron asociados al óbito. Creemos que el control de la TB en niños y adolescentes indígenas no se podrá alcanzar sin inversiones en investigación y desarrollo y sin la reducción de las desigualdades sociales.

Evaluation of Primary Health Care attributes of Fortaleza city, Ceará State, Brazil.

OBJECTIVE: To evaluate the Primary Health Care attributes of Fortaleza city, Ceará State. METHOD: Evaluative study carried out at 97 Primary Health Care Units, from August 2015 to June 2016. 451 professionals from the Family Health Strategy participated in the study. We used the Primary Care Assessment Tool - Brazil, which evaluates the attributes, assigning scores on a scale of zero to ten. We adopted as a cut-off point, to consider high Primary Care score, attributes with a value of 6.60 or higher. RESULTS: Among the eight attributes evaluated the First Contact Access and the Coordination - Information System were the ones that obtained the lowest and highest scores, (2.98) and (7.82), respectively. The Overall Score, calculated by means of a mean of the attributes, was 6.34. CONCLUSION: The Primary Care evaluated had a low score, showing the need to discuss mechanisms to boost the attributes that obtained low scores.

Antenatal care as a means to increase participation in the continuum of maternal and child healthcare: an analysis of the poorest regions of four Mesoamérican countries.

BACKGROUND: Antenatal care (ANC) is a means to identify high-risk pregnancies and educate women so that they might experience a healthier delivery and outcome. There is a lack of evidence about whether receipt of ANC is an effective strategy for keeping women in the system so they partake in other maternal and child interventions, particularly for poor women. The present analysis examines whether ANC uptake is associated with other maternal and child health behaviors in poor mothers in Guatemala, Honduras, Nicaragua, and Mexico (Chiapas). METHODS: We conducted a cross-sectional survey of women regarding their uptake of ANC for their most recent delivery in the last two years and their uptake of selected services and healthy behaviors along a continuity of maternal and child healthcare. We conducted logistic regressions on a sample of 4844 births, controlling for demographic, household, and maternal characteristics to understand the relationship between uptake of ANC and later participation in the continuum of care. RESULTS: Uptake of four ANC visits varied by country from 17.0% uptake in Guatemala to 81.4% in Nicaragua. In all countries but Nicaragua, ANC was significantly associated with in-facility delivery (IFD) (Guatemala odds ratio [OR] = 5.28 [95% confidence interval [CI] 3.62-7.69]; Mexico OR = 5.00 [95% CI: 3.41-7.32]; Honduras OR = 2.60 [95% CI: 1.42-4.78]) and postnatal care (Guatemala OR = 4.82 [95% CI: 3.21-7.23]; Mexico OR = 4.02 [95% CI: 2.77-5.82]; Honduras OR = 2.14 [95% CI: 1.26-3.64]), but did not appear to have any positive relationship with exclusive breastfeeding habits or family planning methods, which may be more strongly determined by cultural influences. CONCLUSIONS: Our results demonstrate that uptake of the WHO-recommended four ANC visits has limited effectiveness on uptake of services in some poor populations in Mesoamérica. Our study highlights the need for continued and varied efforts in these populations to increase both the uptake and the effectiveness of ANC in encouraging positive and lasting effects on women's uptake of health care services.

Evaluation of Primary Health Care attributes of Fortaleza city, Ceará State, Brazil / Evaluación de los atributos de la Atención Primaria de Salud de Fortaleza, Ceará, Brasil / Avaliação dos atributos da Atenção Primária à Saúde de Fortaleza, Ceará, Brasil

ABSTRACT Objective: To evaluate the Primary Health Care attributes of Fortaleza city, Ceará State. Method: Evaluative study carried out at 97 Primary Health Care Units, from August 2015 to June 2016. 451 professionals from the Family Health Strategy participated in the study. We used the Primary Care Assessment Tool - Brazil, which evaluates the attributes, assigning scores on a scale of zero to ten. We adopted as a cut-off point, to consider high Primary Care score, attributes with a value of 6.60 or higher. Results: Among the eight attributes evaluated the First Contact Access and the Coordination - Information System were the ones that obtained the lowest and highest scores, (2.98) and (7.82), respectively. The Overall Score, calculated by means of a mean of the attributes, was 6.34. Conclusion: The Primary Care evaluated had a low score, showing the need to discuss mechanisms to boost the attributes that obtained low scores.

RESUMEN Objetivo: Evaluar los atributos de la Atención Primaria d Salud de Fortaleza-CE. Método: Estudio evaluatorio realizado en 97 Unidades de Atención Primaria a la Salud, en el período de agosto de 2015 a junio de 2016. Participaron de la encuesta 451 profesionales de la Estrategia Salud de la Familia. Se utilizó el Primary Care Assessment Tool - Brasil, que evalúa los atributos, asignando escores en una escala de cero a diez. Se adoptaron como punto de corte, para considerar la puntuación alta de la Atención Primaria, los atributos con un valor igual o superior a 6,60. Resultados: Entre los ocho atributos evaluados, el Acceso de primer contacto y la Coordinación - sistema de informaciones, fueron los que obtuvieron menor y mayor puntaje (2,98) y (7,82), respectivamente. La Escala General, calculada a través de un promedio de los atributos, fue de 6,34. Conclusión La Atención Primaria evaluada obtuvo bajo puntaje, demostrando la necesidad de discutir mecanismos para impulsar los atributos que obtuvieron escores bajos.

RESUMO Objetivo: Avaliar os atributos da Atenção Primária à Saúde de Fortaleza, Ceará. Método: Estudo avaliativo realizado em 97 Unidades de Atenção Primária à Saúde, no período de agosto de 2015 a junho de 2016. Participaram da pesquisa 451 profissionais da Estratégia Saúde da Família. Foi utilizado o Primary Care Assessment Tool - Brasil, que avalia os atributos, atribuindo escores em uma escala de zero a dez. Adotaram-se como ponto de corte, para considerar escore alto da Atenção Primária, os atributos com valor igual ou superior a 6,60. Resultados: Dentre os oito atributos avaliados, o Acesso de primeiro contato e a Coordenação - sistema de informações, foram os que obtiveram menor e maior escore, (2,98) e (7,82), respectivamente. O Escore Geral, calculado através de uma média dos atributos, foi de 6,34. Conclusão: A Atenção Primária avaliada obteve baixo escore, demonstrando a necessidade de se discutir mecanismos para impulsionar os atributos que obtiveram escores baixos.

Patient Satisfaction and Perceived Quality of Care Among Younger Medicare Beneficiaries According to Activity Limitation Stages.

OBJECTIVE: To examine the association between activity limitation stages and patient satisfaction and perceived quality of medical care among younger Medicare beneficiaries. DESIGN: Cross-sectional study. SETTING: Medicare Current Beneficiary Survey (MCBS) for calendar years 2001-2011. PARTICIPANTS: A population-based sample (N=9323) of Medicare beneficiaries <65 years of age living in the community. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: MCBS questions were categorized under 5 patient satisfaction and perceived quality dimensions: care coordination and quality, access barriers, technical skills of primary care physician (PCP), interpersonal skills of PCP, and quality of information provided by PCP. Persons were classified into an activity limitation stage (0-IV) which was derived from self-reported difficulty performing activities of daily living (ADL) and instrumental activities of daily living (IADL). RESULTS: Compared to beneficiaries with no limitations at ADL stage 0, the adjusted odds ratios (95% confidence intervals) for stage I (mild) to stage IV (complete) for satisfaction with access barriers ranged from 0.62 (0.53-0.72) at stage I to a minimum of 0.31 (0.22-0.43) at stage IV. Similarly, compared to beneficiaries at IADL stage 0, satisfaction with access barriers ranged from 0.66 (0.55-0.79) at stage I to a minimum of 0.36 (0.26-0.51) at stage IV. Satisfaction with care coordination and quality and perceived quality of medical care were not associated with activity limitation stages. CONCLUSIONS: Younger Medicare beneficiaries with disabilities reported decreased satisfaction with access to medical care, highlighting the need to improve access to health care and human services and to enhance workforce capacity to meet the needs of this patient population.