Presencia de egresados y egresadas de la Universidad Nacional del Sur en el sistema de residencias médicas de Bahía Blanca / Presence of graduates from the National University of the Sur in the medical residency system of Bahía Blanca

Introducción: La atracción, captación y retención son determinantes de una distribución equitativa de profesionales de la salud. Objetivo: describir las decisiones de formación de posgrado de egresados/as de medicina de la Universidad Nacional del Sur (UNS), y su impacto en el sistema de residencias médicas de Bahía Blanca durante el año 2023. Resultados: el 79,63% de quienes egresaron de esta universidad decidieron realizar una residencia médica, y el 51,12 % adjudicó en especialidades del Primer Nivel de Atención con una adjudicación en pediatría menor a la media nacional. La carrera de medicina local cubrió el 39,24 % de las vacantes de Bahía Blanca, y el 38% de sus graduados/as decidió formarse en otras ciudades. Ocho residencias de la ciudad quedaron sin ingresantes en el 2023. Conclusión: existe una gran proporción de egresados/as de la UNS que eligen especialidades de APS. Hay una baja adjudicación en Pediatría que contrasta con la elección de Medicina Familiar, a diferencia de las elecciones a nivel nacional. En términos generales hay un déficit en la atracción y captación de egresados/as de la UNS por parte del sistema de salud local, lo cual demanda a los sectores docentes y asistenciales nuevas estrategias para captar y atraer profesionales en área prioritarias (AU)

Introduction: Attraction, recruitment and retention are determinants of an equitable distribution of healthcare professionals. Objective: to describe the postgraduate training decisions of medical graduates from the National University of the South (UNS), and their impact on the Bahía Blanca medical residency system during the year 2023. Results: 79.63% of Those who graduated from this university decided to carry out medical residency, and 51.12% were awarded in First Level Care specialties with a pediatric award lower than the national average. The local medical career covered 39.24% of the vacancies in Bahía Blanca, and 38% of its graduates decided to train in other cities. Eight residences in the city were left without entrants in 2023. Conclusion: there is a large proportion of UNS graduates who choose APS specialties. There is a low allocation in Pediatrics that contrasts with the choice of Family Medicine, unlike the elections at the national level. In general terms, there is a deficit in the attraction and recruitment of UNS graduates by the local health system, which demands new strategies from the teaching and healthcare sectors to attract and attract professionals in priority areas (AU)

Educational Strategies to Reduce Physician Shortages in Underserved Areas: A Systematic Review.

The shortage of physicians in rural and underserved areas is an obstacle to the implementation of Universal Health Coverage (UHC). We carried out a systematic review to analyze the effectiveness of initiatives in medical education aimed to increase the supply of physicians in rural or underserved areas. We searched for studies published between 1999 and 2019 in six databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Interventional or observational controlled studies were defined as inclusion criteria. A total of 955 relevant unique records were selected for inclusion, which resulted in the identification of 17 articles for analysis. The admission of students from rural areas associated with a rural curriculum represented 52.95% of the interventions. Medical practice after graduation in rural or underserved areas was the most evaluated outcome, representing 12 publications (70.59%). Participants of these educational initiatives were more likely to work in rural or underserved areas or to choose family medicine, with significant differences between the groups in 82.35% of the studies. Educational strategies in undergraduate and medical residencies are effective. However, it is necessary to expand these interventions to ensure the supply of physicians in rural or urban underserved areas.

Profesionales médicos cubanos para la atención primaria de salud: el caso de Portugal / Cuban health personnel for primary health care: the Portugal case

RESUMEN Objetivo Analizar el proceso de contratación de médicos cubanos por parte del Gobierno de Portugal y comprender la percepción de los profesionales cubanos sobre el ejercicio de la profesión en el exterior. Métodos Se realizó un estudio de caso cualitativo-descriptivo-analítico, con triangulación de datos a partir de la recolección de información de múltiples fuentes de evidencia. Se entrevistó a un total de 16 informantes clave, se analizaron documentos y se realizó observación directa. Resultados Los resultados más evidentes muestran que se estableció una cooperación para hacer frente a la escasez crónica de médicos en atención primaria; la elección de médicos de nacionalidad cubana tiene una dimensión política. Se llevó a cabo un acuerdo entre las partes para permitir el registro de médicos cubanos en la Orden de Médicos de Portugal. Conclusiones Hubo un resultado positivo en la contratación de médicos cubanos por parte de Portugal, ya que aumentó el número de usuarios con acceso a los servicios y también se tuvo una brecha de tiempo para que el gobierno tomara algunas medidas para mitigar el problema de la escasez de médicos.

ABSTRACT Objective To analyze the process of recruitment of Cuban doctors by the government of Portugal and to understand the perception of these Cubans about the exercise of their professions abroad. Methods A qualitative-descriptive-analytical case study was carried out, with data triangulation, based on the collection of information from multiple sources of evidence. Sixteen key informants were interviewed, documents were analyzed, and direct observation was carried out. Results The most evident results demonstrate that the cooperation was established to address the chronic shortage of doctors in primary care; the choice of Cuban doctors had a political dimension. An arrangement was made to enable the registration of Cuban doctors in the Portuguese Medical Association. Conclusions There was a positive outcome in the recruitment of Cuban doctors by Portugal since it increased the number of patients with access to services, and allowed a time gap for the government to take some measures in order to mitigate the problem of shortage of doctors.

¿Cómo evolucionó la distribución de médicas y médicos especialistas en Argentina?: un análisis demográfico de la profesión médica al 2020 / How did the distribution of doctors and medical specialists evolve in Argentina?: a demographic analysis of the medical profession to 2020

Las políticas sobre trabajadores/as de salud deben garantizar su distribución adecuada. En Argentina dicha distribución es desigual, sobre todo en especialistas en atención primaria de la salud (APS). El objetivo de este trabajo fue describir la distribución de médicos/as, especialistas lineales y en APS en Argentina, durante el año 2020, teniendo en cuenta la situación económica y sanitaria de cada jurisdicción. Se trata de un trabajo descriptivo y analítico, que utilizó fuentes de datos primarias y secundarias. Se correlacionó la tasa de mortalidad infantil y el producto bruto per cápita de cada jurisdicción ordenándolas de mejores a peores indicadores. La tasa de médicos fue 3,88 médicos/as cada 1000 habitantes, 72% concentrándose en 4 jurisdicciones (Ciudad Autónoma de Buenos Aires, Provincia de Buenos Aires, Córdoba y Santa Fe). El 53% son especialistas y el 27,6% lo son en APS. CABA tuvo una tasa de 16,5 médicos/as por mil; Santiago del Estero y Formosa alcanzaron valores de 1,8 y 1,9 médicas/os por mil habitantes respectivamente. Con respecto a 2014, se observó disminución de especialistas en APS (-14,8%), registrándose las mayores pérdidas en Santiago del Estero, Formosa y Catamarca (-84,5%; -70,1% y -87,3%). La situación nacional sobre la distribución de médicos/as en Argentina desde 1954 a la actualidad fue empeorando en detrimento de las provincias con mayores necesidades. La baja adherencia al sistema de residencias a especialidades de APS pronostica un empeoramiento de la situación de no haber cambios estructurales. Será necesario un fortalecimiento del rol rector del estado en el abordaje de esta problemática (AU)

Policies on health workers must guarantee their adequate distribution. In Argentina, this distribution is unequal, particularly among primary care specialists (PHC).The objective of this article is to describe the distribution of physicians, PHC and non-PHC specialists in Argentina in 2020, considering the economic and health situation of each jurisdiction.We conducted a descriptive cross-sectional study with an analytical stage using primary and secondary data sources. The jurisdictions were classified according to the correlation between infant mortality rate and gross product per capita.The rate of physicians in Argentina in 2020 was 3.88 physicians per 1,000 inhabitants. 72% are concentrated in 4 jurisdictions (City of Buenos Aires, Province of Buenos Aires, Córdoba and Santa Fe). 53% are specialists and 27.6% are PHC specialists. The City of Buenos Aires has a rate of 16.5 physicians per thousand; and Santiago del Estero and Formosa reach values of 1.8 and 1.9 physicians per thousand inhabitants, respectively.There was a decrease in PHC specialists (-14.8%), with major losses recorded in Santiago del Estero, Formosa and Catamarca (-84.5%; -70.1% and -87.3%, respectively).The distribution of physicians in Argentina from 1954 to the present has worsened to the detriment of the provinces with the greatest needs. The lack of adheren-ce to the specialty of PHC predicts a worsening of the situation if there are no structural changes. It is necessary to strengthen the leading role of the state in addressing this problem (AU)

Stroke and Myocardial Infarction: Effects of the "Hiperdia" and "Mais Médicos" Programs on the Hospitalizations Trends in Brazil

Abstract Background Stroke and acute myocardial infarction (AMI) are cardiovascular diseases commonly characterized by the development of atheromatous plaques associated with major complications and high mortality rates. Objective To identify an epidemiological trend in hospitalizations due to stroke and AMI and to analyze the relationship between health programs applied in Primary Health Care, gender and the Federative Unit. Methods Ecological study with a time series design between 1998 and 2018, collecting data from all federal units in Brazil stratified by, gender and place of residence. There were analyzed Hospitalization Authorizations (AIH) for stroke and MI, consulting the Hospital Admissions System (SIH) of the Informatics Department of the National Health Service with p <0.05. Results From 1998 to 2018, the rate of hospitalization for AMI increased in Brazil approximately 42.58 events per 100 thousand inhabitants annually (p<0.001), while hospitalizations for stroke declined 32.17 cases (p=0.03). This pattern was observed in both sexes in AMI and stroke. There is also evidence of the effect of the Hiperdia (p<0.001) and Mais Médicos (p=0.001) program in reducing stroke and Hiperdia cases in mitigating the evolution of AMI cases (p = 0.0001). Conclusion Although these diseases remain as an important cause of death, stroke hospitalization has reduced significantly in the period evaluated. National programs as the Hiperdia and Mais Médicos showed an impact in the acute cases of strokes and AMI.

Recrutamento e retenção de médicos para a Atenção Básica: permanentes desafios para o Brasil / Recruitment and retention of physicians for Primary Health Care: permanent challenges for Brazil

O objetivo deste estudo é analisar as evidências científicas e documentais sobre as estratégias relacionadas ao recrutamento e à retenção de médicos para Atenção Básica (AB) e implementadas pelo Programa Mais Médicos. Trata-se de uma revisão integrativa que incluiu documentos oficiais sobre o PMM e artigos sobre recrutamento e retenção de médicos na AB. As estratégias encontradas na literatura foram formação médica, incentivos aos médicos, características intrínsecas ao médico e à localidade, investimento em infraestrutura e recrutamento de médicos intercambistas. O PMM contemplou todas essas categorias, porém não contemplou todas as subcategorias encontradas na literatura, como presença de equipe interprofissional. Portanto, as medidas implementadas a partir do Programa encontram-se em consonância com as estratégias mais apontadas na literatura atual sobre recrutamento e retenção de médicos na AB.

The aim of this study is to analyze the scientific and documentary evidence on the strategies related to the recruitment and retention of doctors for Primary Care (AB) and those implemented by the Mais Médicos Program. It is an integrative review that included official documents on the PMM and articles on recruiting and retaining doctors in AB. The strategies found in the literature were medical training, incentives for doctors, characteristics intrinsic to the doctor and the location, investment in infrastructure and recruitment of exchange students. The PMM covered all of these categories, but did not include all the subcategories found in the literature, such as the presence of an interprofessional team. Therefore, the measures implemented from the Program are in line with the most pointed strategies in the current literature on the recruitment and retention of doctors in AB.

Evaluating medical education regulation changes in Brazil: workforce impact.

BACKGROUND: Shortages and inequitable distribution of physicians is an obstacle to move towards Universal Health Coverage, especially in low-income and middle-income countries. In Brazil, expansion of medical school enrollment, curricula changes and recruitment programs were established to increase the number of physicians in underserved areas. This study seeks to analyze the impact of these measures in reduce inequities in access to medical education and physicians' distribution. METHODS: This is an observational study that analyzes changes in the number of undergraduate medical places and number of physicians per inhabitants in different areas in Brazil between the years 2010 and 2018. Data regarding the number of undergraduate medical places, number and the practice location of physicians were obtained in public databases. Municipalities with less than 20,000 inhabitants were considered underserved areas. Data regarding access to antenatal visits were analyzed as a proxy for impact in access to healthcare. RESULTS: From 2010 to 2018, 19,519 new medical undergraduate places were created which represents an increase of 120.2%. The increase in the number of physicians engaged in the workforce throughout the period was 113,702 physicians, 74,771 of these physicians in the Unified Health System. The greatest increase in the physicians per 1000 inhabitants ratio in the municipalities with the smallest population, the lowest Gross Domestic Product per capita and in those located in the states with the lowest concentration of physicians occurred in the 2013-2015 period. Increase in physician supply improved access to antenatal care. CONCLUSIONS: There was an expansion in the number of undergraduate medical places and medical workforce in all groups of municipalities assessed in Brazil. Medical undergraduate places expansion in the federal public schools was more efficient to reduce regional inequities in access to medical education than private sector expansion. The recruitment component of More Doctors for Brazil Program demonstrated effectiveness to increase the number of physicians in underserved areas. Our results indicate the importance of public policies to face inequities in access to medical education and physician shortages and the necessity of continuous assessment during the period of implementation, especially in the context of political and economic changes.

Cell phone usefulness to improve the skin cancer screening: preliminary results and critical analysis of mobile app development.

INTRODUCTION: The high incidence of skin cancer in Brazil has resulted in an urgent need for more efficient methods of reducing the time between initial diagnosis and therapy. Such delays are significant in large countries like Brazil, where a considerable proportion of the population live in remote areas with limited access to specialized medical care. To address this problem the use of mobile phones as screening devices for suspicious skin lesions has been incorporated as long-distance teledermatology services. Digital photography is now a convenient ancillary option to minimize treatment delays caused by the distance between the specialist doctor and patients. The authors have developed a friendly mobile application and website to take high quality digital images of suspicious lesions, and to capture patient data easily and quickly to be analyzed by skin cancer professionals at another location. METHODS: This was a prospective study of a population of 39 individuals monitored by routine skin cancer screening by the Cancer Prevention Department at Barretos Cancer Hospital during 2016. All patients were evaluated in the dermatology clinic, where a differential diagnosis was made based on the clinical information and direct examination of suspicious lesions. A second dermatologist assessed the same clinical information and digital images of all lesions captured by teledermatology, and provided an independent diagnostic opinion on the likelihood of the lesions being benign or suggestive of malignancy. The diagnostic efficiencies of teledermatology and standard dermatology were then compared to the histopathological findings of each biopsy as the diagnostic gold standard, and then statistical parameters of each approach were evaluated. RESULTS: The lesions studied in this comparison were mostly found on the face (69%), followed by upper limbs (15%), scalp (8%), trunk (6%) and lower limbs (2%). Final histopathological analyses of the biopsies in the study group showed that 71% of lesions were malignant, with 32% being squamous cell carcinoma and 68% being classified as basal cell carcinoma, and 29% were considered benign lesions. The overall sensitivities of teledermatology in comparison to face-to-face evaluation in the clinic were similar (clinic, 80.0%; teledermatology, 80.8%). Other comparisons including accuracy (clinic, 78.9%; teledermatology, 79.5%); specificity (clinic, 76.9%; teledermatology, 76.9%); positive predictive value (clinic, 87.0%; teledermatology, 87.5%); and negative predictive value (clinic, 66.7.0%; teledermatology, 66.7%) all showed equivalence. The inter-observer kappa value between face-to-face examination and teledermatology showed excellent agreement at 0.958. CONCLUSION: These preliminary findings indicate that the cell phone application developed to aid the diagnosis of skin cancer showed great potential and reliability, and can therefore be considered as an ancillary option in countries like Brazil, with isolated communities that have limited access to dermatology clinics.

The More Doctors Program in remote areas: the experience of the Special Supervision Group in Pará, Brazil / O Programa Mais Médicos em áreas remotas: a experiência do Grupo Especial de Supervisão no Pará, Brasil / El Programa Más Médicos en áreas remotas: la experiencia del Grupo Especial de Supervisión en el estado de Pará, Brasil

The More Doctors Program encompasses an academic supervision carried out by supervisory institutions that have signed an agreement with the Ministry of Education (MEC). Academic supervision is part of the educational offers and implies periodic and regular visits to participant doctors. However, due to the difficulties of some institutions in the North region to fulfill their responsibilities under the Project More Doctors for Brazil, MEC created the Special Supervision Group (GES), which has been operating since 2014 in that region. This article records the GES experience in the state of Pará from January 2015 to May 2017. Its main contribution is to enable the provision of care for the population that inhabits a vast region where there is shortage of doctors, as the supervision of the professionals is mandatory and if it did not occur, the Program would not be allowed in Pará.(AU)

O Programa Mais Médicos (PMM) abrange, no eixo provimento, a supervisão acadêmica, realizada por instituições supervisoras (IS) que firmaram termo de adesão com o Ministério da Educação (MEC). A supervisão é parte das ofertas educacionais e implica visita periódica e regular aos médicos participantes do PMM. Entretanto, devido às dificuldades de algumas IS da região Norte cumprirem o que lhes cabe no âmbito do Projeto Mais Médicos para o Brasil (PMMB), o MEC criou o Grupo Especial de Supervisão (GES), que atua desde 2014 nessa região. Este artigo registra a experiência do GES no estado do Pará no período de janeiro de 2015 a maio de 2017. Sua principal contribuição é possibilitar o atendimento à população habitante de uma região vasta e com notória escassez de médicos, uma vez que a supervisão dos profissionais é obrigatória e, caso ausente, inviabilizaria o programa no Pará.(AU)

El Programa Más Médicos (PMM) abarca la supervisión académica realizada por las Instituciones Supervisoras (IS) que hayan firmado documento de adhesión con el Ministerio de la Educación (MEC). La supervisión académica es parte de las ofertas educativas e implica una visita periódica y regular a los médicos del PMM. Sin embargo, debido a las dificultades de algunas IS de la región Norte para cumplir sus responsabilidades en el ámbito del PMMB, el MEC creó el Grupo Especial de Supervisión (GES), que actúa desde 2014 en la región. Este artículo registra la experiencia del GES en el estado de Pará en el período de enero de 2015 a mayo de 2017. Su contribución es hacer posible la asistencia a una población que habita una vasta región con notable escasez de médicos, una vez que la supervisión de los profesionales es obligatoria y si no la hubiera inviabilizaría el Programa en el Estado de Pará.(AU)

A Remote Collaborative Care Program for Patients with Depression Living in Rural Areas: Open-Label Trial.

BACKGROUND: In the treatment of depression, primary care teams have an essential role, but they are most effective when inserted into a collaborative care model for disease management. In rural areas, the shortage of specialized mental health resources may hamper management of depressed patients. OBJECTIVE: The aim was to test the feasibility, acceptability, and effectiveness of a remote collaborative care program for patients with depression living in rural areas. METHODS: In a nonrandomized, open-label (blinded outcome assessor), two-arm clinical trial, physicians from 15 rural community hospitals recruited 250 patients aged 18 to 70 years with a major depressive episode (DSM-IV criteria). Patients were assigned to the remote collaborative care program (n=111) or to usual care (n=139). The remote collaborative care program used Web-based shared clinical records between rural primary care teams and a specialized/centralized mental health team, telephone monitoring of patients, and remote supervision by psychiatrists through the Web-based shared clinical records and/or telephone. Depressive symptoms, health-related quality of life, service use, and patient satisfaction were measured 3 and 6 months after baseline assessment. RESULTS: Six-month follow-up assessments were completed by 84.4% (221/250) of patients. The remote collaborative care program achieved higher user satisfaction (odds ratio [OR] 1.94, 95% CI 1.25-3.00) and better treatment adherence rates (OR 1.81, 95% CI 1.02-3.19) at 6 months compared to usual care. There were no statically significant differences in depressive symptoms between the remote collaborative care program and usual care. Significant differences between groups in favor of remote collaborative care program were observed at 3 months for mental health-related quality of life (beta 3.11, 95% CI 0.19-6.02). CONCLUSIONS: Higher rates of treatment adherence in the remote collaborative care program suggest that technology-assisted interventions may help rural primary care teams in the management of depressive patients. Future cost-effectiveness studies are needed. TRIAL REGISTRATION: Clinicaltrials.gov NCT02200367; https://clinicaltrials.gov/ct2/show/NCT02200367 (Archived by WebCite at http://www.webcitation.org/6xtZ7OijZ).

Remote Collaborative Depression Care Program for Adolescents in Araucanía Region, Chile: Randomized Controlled Trial.

BACKGROUND: Despite evidence on efficacious interventions, a great proportion of depressed adolescents do not receive evidence-based treatment and have no access to specialized mental health care. Remote collaborative depression care (RCDC) may help to reduce the gap between needs and specialized mental health services. OBJECTIVE: The objective of this study was to assess the feasibility, acceptability, and effectiveness of an RCDC intervention for adolescents with major depressive disorder (MDD) living in the Araucanía Region, Chile. METHODS: A cluster randomized, assessor-blind trial was carried out at 16 primary care centers in the Araucanía Region, Chile. Before randomization, all participating primary care teams were trained in clinical guidelines for the treatment of adolescent depression. Adolescents (N=143; 13-19 years) with MDD were recruited. The intervention group (RCDC, N=65) received a 3-month RCDC treatment that included continuous remote supervision by psychiatrists located in Santiago, Chile's capital city, through shared electronic health records (SEHR) and phone patient monitoring. The control group (enhanced usual care or EUC; N=78) received EUC by clinicians who were encouraged to follow clinical guidelines. Recruitment and response rates and the use of the SEHR system were registered; patient adherence and satisfaction with the treatment and clinician satisfaction with RCDC were assessed at 12-week follow-up; and depressive symptoms and health-related quality of life (HRQoL) were evaluated at baseline and 12-weeks follow-up. RESULTS: More than 60.3% (143/237) of the original estimated sample size was recruited, and a response rate of 90.9% (130/143) was achieved at 12-week follow-up. A mean (SD) of 3.5 (4.0) messages per patient were written on the SEHR system by primary care teams. A third of the patients showed an optimal adherence to psychopharmacological treatment, and adolescents in the RCDC intervention group were more satisfied with psychological assistance than those in EUC group. Primary care clinicians were satisfied with the RCDC intervention, valuing its usefulness. There were no significant differences in depressive symptoms or HRQoL between groups. Satisfaction with psychological care, in both groups, was related to a significant change in depressive symptomatology at 12-weeks follow-up (beta=-4.3, 95% CI -7.2 to -1.3). CONCLUSIONS: This is the first trial of its kind in Latin America that includes adolescents from vulnerable backgrounds, with an intervention that proved to be feasible and well accepted by both patients and primary care clinicians. Design and implementation issues may explain similar effectiveness across arms. The effectiveness of the intervention seems to be comparable with an already nationwide established treatment program that proved to be highly efficacious under controlled conditions. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01860443; https://clinicaltrials.gov/ct2/show/NCT01860443 (Archived by WebCite at http://www.webcitation.org/6wafMKlTY).

Fatores que influenciaram o processo de formulação de políticas de recursos humanos em saúde no Brasil e em Portugal: estudo de caso múltiplo / Factores que influenciaron el proceso de formulación de políticas de recursos humanos en salud en Brasil y Portugal: estudio de caso múltiple / Factors that influence human resources for health policy formulation: a multiple case study in Brazil and Portugal

O estudo objetiva analisar o processo em que as políticas de recursos humanos em saúde (RHS), que visam melhorar a distribuição geográfica dos médicos, são (ou não) informadas por evidência científica no Brasil e em Portugal. Foi realizado um estudo de caso-múltiplo sobre o processo de decisão das políticas de RHS no Brasil e em Portugal. Para compor os estudos de caso, as políticas escolhidas foram o Programa Mais Médicos (PMM) e a estratégia de contratação de médicos estrangeiros por acordos bilaterais para o trabalho no Serviço Nacional de Saúde (SNS) português. Foram entrevistados 27 atores-chave no processo de formulação das políticas em análise nos seguintes tópicos: fatores que influenciaram a formulação, atores que eram esperados ganhar ou perder, evidências científicas e os dados disponíveis utilizados para a formulação, entre outros. Os fatores mais evidentes identificados nas entrevistas como sendo influenciadores do PMM foram: Instituições; Fatores Externos (eleições presidenciais); Interesses de grupos (por exemplo, associações de profissionais médicos), governos (brasileiro e cubano), organização internacional e sociedade civil; e Ideias (evidência científica). Os fatores mais listados em Portugal foram: Instituições e Interesses dos governos (português e envolvidos nos acordos bilaterais), sociedade civil e grupos (associações de profissionais médicos). Ao contrário do que se verificou no estudo de caso do Brasil, em que reconhecidamente a evidência teve um papel importante na formulação da política em análise, em Portugal a evidência científica não foi identificada como contributo para a formulação da intervenção em estudo.(AU)

El estudio tiene por objetivo analizar el proceso en el que las políticas de recursos humanos en salud (RHS), que tienen como fin la mejora de la distribución geográfica de los médicos, son (o no) informadas por evidencias científicas en Brasil y en Portugal. Se trata de un estudio de caso-múltiple sobre el proceso de decisión de las políticas de RHS en Brasil y en Portugal. Para configurar los estudios de caso, las políticas elegidas fueron el Programa Más Médicos (PMM) y la estrategia de contratación de médicos extranjeros mediante acuerdos bilaterales para el trabajo en el Servicio Nacional de Salud (SNS) portugués. Se entrevistaron a 27 actores-clave en el proceso de formulación de las políticas en el análisis en los siguientes asuntos: factores que influenciaron la formulación, actores que se esperaba ganar o perder, evidencias científicas y datos disponibles utilizados para la formulación, entre otros. Los factores más evidentes, identificados en las entrevistas como de influencia en el PMM, fueron: instituciones; factores externos (elecciones presidenciales); intereses de grupos (por ejemplo, asociaciones de profesionales médicos), gobiernos (brasileño y cubano), organización internacional y sociedad civil; e ideas (evidencia científica). Los factores más registrados en Portugal fueron: instituciones e intereses de los gobiernos (como el portugués y los involucrados en los acuerdos bilaterales), sociedad civil y grupos (asociaciones de profesionales médicos). Al contrario de lo que se verificó en el estudio de caso de Brasil, donde se reconoció que la evidencia tuvo un papel importante en la formulación de la política en análisis, en Portugal la evidencia científica no fue identificada como una contribución para la formulación de la intervención en estudio.(AU)

This study aims to analyze whether the process by which policies for human resources for health that aim to improve the geographic distribution of physicians have been informed by scientific evidence in Brazil and Portugal. This was a multiple case study on a decision-making process for human resources for health in Brazil and Portugal. The respective case studies were based on Brazil's More Doctors Program (Programa Mais Médicos - PMM) and Portugal's strategy of hiring foreign physicians through bilateral agreements, to work in the country's National Health Service (SNS). We interviewed 27 key actors in the policy-making process on the following topics: factors that influenced the policy decisions, actors that were expected to win or lose from the policy, and the scientific evidence and available data used in the policy-making, among others. The most evident factors appearing in the interviews as having influenced the PMM were: institutions; external factors (Presidential elections); group interests (e.g. physicians' professional associations), governments (Brazil and Cuba), international organizations, and civil society; and ideas (scientific evidence). The most frequently cited factors in Portugal were: institutions and interests of government (from Portugal and the countries involved in the bilateral agreements), civil society, and groups (physicians' professional associations). Contrary to the case study in Brazil, where the evidence was reported to having played an important role in the policy decisions, in Portugal, scientific evidence was not identified as contributing to the specific policy process.(AU)

Distancia al centro de atención en salud y mortalidad durante los primeros años de vida: revisión sistemática y metaanálisis / Distance from healthcare facilities and early life mortality: a systematic review and meta-analysis / Distância ao centro de atendimento em saúde e mortalidade durante os primeiros anos de vida: revisão sistemática e meta-análise

Resumen Objetivo: actualizar las revisiones sistemáticas sobre el efecto de la distancia a los centros de atención en salud, en la mortalidad de menores de 5 años, con artículos publicados hasta mayo de 2015. Metodología: revisión sistemática con metaanálisis según recomendaciones de PRISMA. Se estimó un modelo de efectos aleatorios y se realizaron análisis de sesgo y de heterogeneidad de las estimaciones. Resultados: residir a más de 5 km del centro de atención de salud se asocia con un mayor riesgo de muerte en los periodos perinatal OR 2,76 (IC95% 1,80- 4,23), neonatal OR 1,62 (IC95% 1,33-1,96), infantil OR 1,31 (IC95% 1,16- 1,48), durante la niñez OR 1,57 (IC95% 1,29-1,92) y en todos los grupos de edad OR 1,63 (IC95% 1,41-1,88). Conclusión: se resalta la importancia de considerar una distribución geográfica de los centros de atención en salud, que permita a los menores residentes en áreas remotas menores riesgos de muerte, particularmente durante el primer mes de vida.

Abstract Objective: to update the systematic reviews of the literature discussing the effect of the distance from healthcare facilities on the mortality of children under five years of age using academic papers up to May, 2015. Methodology: a systematic review of the literature and a meta-analysis conducted in accordance with the PRISMA guidelines. A random effect model was estimated and bias and heterogeneity analyses were conducted on the estimates. Results: residing farther than 5 km away from the closest healthcare facility is associated with a greater risk of death during the following periods: perinatal OR 2.76 (CI95% 1.80 - 4.23), neonatal OR 1.62 (CI95% 1.33 - 1.96), infancy OR 1.31 (CI95% 1.16 - 1.48) childhood OR 1.57 (CI95% 1.29 - 1.92) and all age groups OR 1.63 (IC95% 1.41 - 1.88). Conclusión: the authors highlight the importance of considering a geographical distribution of healthcare facilities which reduces death risk among children residing in remote areas, particularly during the first month of life.

Resumo Objetivo: atualizar as revisões sistemáticas sobre o efeito da distância aos centros de atendimento em saúde, na mortalidade de menores de 5 anos, com artigos publicados até maio de 2015. Metodologia: revisão sistemática com meta-análise segundo recomendações de PRIMA. Estimou-se um modelo de efeitos aleatórios e se realizaram análises de distorção e de heterogeneidade das estimações. Resultados: morar a mais de 5 km do posto de atendimento de saúde está associado com um maior risco de morte nos períodos perinatal OR 2,76 (IC95% 1,80 - 4,23), neonatal OR 1,62 (IC95% 1,33-1,96), infantil OR 1,31 (IC95% 1,16-1,48), durante a infância OR 1,57 (IC95% 1,29-1,92) e em todos os grupos etários OR 1,63 (IC95% 1,41-1,88). Conclusão: Salienta-se a importância de considerar uma distribuição geográfica dos postos de atendimento em saúde, permitindo às crianças moradoras em áreas distantes, menores riscos de morte, particularmente durante o primeiro mês de vida.

Preferências para o trabalho na atenção primária por estudantes de medicina em Minas Gerais, Brasil: evidências de um experimento de preferência declarada / Preferences for work in primary care among medical students in Minas Gerais State, Brazil: evidence from a discrete choice experiment / Preferencias para el trabajo en la atención primaria por parte de estudiantes de medicina en Minas Gerais, Brasil: evidencias de un experimento de preferencia declarada

Este artigo tem por objetivo apresentar os resultados da aplicação de um experimento de preferência declarada (DCE - discrete choice experiment) realizado em 2012 com 277 estudantes do último ano dos cursos de medicina do Estado de Minas Gerais, Brasil. O experimento permitiu investigar as preferências dos estudantes sobre o trabalho futuro como médicos na atenção primária à saúde, com base em de cenários de emprego hipotéticos que visavam aferir a probabilidade de deslocamento para áreas com escassez de médicos. A aplicação do DCE envolveu (i) uma etapa qualitativa para definição dos atributos e seus respectivos níveis que comporiam os cenários de emprego, (ii) uma etapa de construção e aplicação do instrumento e (iii) uma etapa de análise com a aplicação de logit multinomial de probabilidade condicional para estimativa dos pesos de cada atributo e construção de cenários de probabilidade de escolha. Os resultados apontaram que o atributo do emprego que mais impactou a escolha dos respondentes foi o de localização do trabalho, seguido por condições de trabalho, remuneração, acesso à residência médica, tipo de vínculo e carga de trabalho. Constatou-se que os entrevistados de faculdades privadas, com maior renda familiar e do sexo feminino, em geral, têm maior resistência para deslocar-se para as regiões urbanas inseguras e áreas remotas do interior. Os cenários de emprego que se mostraram mais plausíveis em termos de intervenção pública foram aqueles que combinavam os salários de valores intermediários, boas condições de trabalho e obtenção de 10 a 20 pontos adicionais nos exames de residência médica.

This article presents the results of a discrete choice experiment (DCE) conducted in 2012 with 277 final-year medical students from Minas Gerais State, Brazil. The experiment tested students' preferences concerning future work as physicians in primary health care, based on hypothetical job scenarios aimed at measuring the likelihood of placement in areas with a shortage of doctors. Application of DCE involved (i) a qualitative stage to define the attributes and their respective levels to comprise the job scenarios, (ii) construction and application of the instrument, and (iii) analysis with application of multinomial logit with conditional probability to estimate the weight of attributes and to construct scenarios for choice probability. The results indicate that the job attribute that most impacted students' choice was location, followed by job conditions, pay, access to medical residency, type of employment relationship, and workload. Students from private medical schools, with higher family income, and females were generally more likely to resist job assignments in unsafe urban areas and remote areas of the countryside. The job scenarios that proved most plausible in terms of public intervention were those that combined middle-level wages, good working conditions, and 10 to 20 bonus points on medical residency exams.

This article presents the results of a discrete choice experiment (DCE) conducted in 2012 with 277 final-year medical students from Minas Gerais State, Brazil. The experiment tested students' preferences concerning future work as physicians in primary health care, based on hypothetical job scenarios aimed at measuring the likelihood of placement in areas with a shortage of doctors. Application of DCE involved (i) a qualitative stage to define the attributes and their respective levels to comprise the job scenarios, (ii) construction and application of the instrument, and (iii) analysis with application of multinomial logit with conditional probability to estimate the weight of attributes and to construct scenarios for choice probability. The results indicate that the job attribute that most impacted students' choice was location, followed by job conditions, pay, access to medical residency, type of employment relationship, and workload. Students from private medical schools, with higher family income, and females were generally more likely to resist job assignments in unsafe urban areas and remote areas of the countryside. The job scenarios that proved most plausible in terms of public intervention were those that combined middle-level wages, good working conditions, and 10 to 20 bonus points on medical residency exams.

Surgery in Brazilian Health Care: funding and physician distribution / Cirurgia no Sistema Brasileiro de Saúde: financiamento e distribuição de médicos

ABSTRACT Objective: to analyze demographic Brazilian medical data from the national public healthcare system (SUS), which provides free universal health coverage for the entire population, and discuss the problems revealed, with particular focus on surgical care. Methods: data was obtained from public healthcare databases including the Medical Demography, the Brazilian Federal Council of Medicine, the Brazilian Institute of Geography and Statistics, and the National Database of Healthcare Establishments. Density and distribution of the medical workforce and healthcare facilities were calculated, and the geographic regions were analyzed using the public private inequality index. Results: Brazil has an average of two physicians for every 1,000 inhabitants, who are unequally distributed throughout the country. There are 22,276 board certified general surgeons in Brazil (11.49 for every 100,000 people). The country currently has 257 medical schools, with 25,159 vacancies for medical students each year, with only around 13,500 vacancies for residency. The public private inequality index is 3.90 for the country, and ranges from 1.63 in the Rio de Janeiro up to 12.06 in Bahia. Conclusions: A significant part of the local population still faces many difficulties in accessing surgical care, particularly in the north and northeast of the country, where there are fewer hospitals and surgeons. Physicians and surgeons are particularly scarce in the public health system nationwide, and better incentives are needed to ensure an equal public and private workforce.

RESUMO Objetivo: analisar dados demográficos do Sistema Único de Saúde (SUS) brasileiro, que promove cobertura de saúde universal a toda população, e discutir os problemas revelados, com particular ênfase nos cuidados cirúrgicos. Métodos: os dados foram obtidos a partir dos bancos de dados de saúde pública da Demografia Médica, do Conselho Federal de Medicina, do Instituto Brasileiro de Geografia e Estatística e do Cadastro Nacional dos Estabelecimentos de Saúde. A densidade e a distribuição do trabalho médico e dos estabelecimentos de saúde foram avaliadas, e as regiões geográficas foram analisadas usando o índice de desigualdade público-privado (IDPP). Resultados: o Brasil tem, em média, dois médicos por 1000 habitantes, que são desigualmente distribuídos no país. Tem 22.276 cirurgiões gerais certificados (11,49 por 100.000 habitantes). Existem no país 257 escolas de medicina, com 25.159 vagas por ano, e apenas cerca de 13.500 vagas de residência médica. O índice de desigualdade público-privado é de 3,90 para o país e varia de 1,63 no Rio de Janeiro até 12,06 na Bahia. Conclusão: uma parte significativa da população brasileira ainda encontra muitas dificuldades no acesso ao tratamento cirúrgico, particularmente na região norte e nordeste do país. Médicos e, particularmente, cirurgiões são escassos no sistema público de saúde e incentivos devem ser criados para assegurar uma força médica igual no setor público e no setor privado em todas as regiões do país.

Accesibilidad geográfica al cuidado obstétrico y neonatal y su efecto en la mortalidad neonatal temprana en Colombia 2012-2014 / Geographical Accessibility to Obstetric and Neonatal Care and its Effect on Early Neonatal Mortality in Colombia, 2012-2014

Introduction: The distribution of health resources influences early neonatal mortality, granting access to obstetric care which is a major public health problem. However, the geographical dimension of this influence has not been studied in Colombia. Objective: To describe the geographical accessibility to obstetric and neonatal care beds and its association with early neonatal mortality in Colombia and its municipalities. Method: An ecological study at municipal level was carried out. Ordinary least squares (OLS) regression and a geographically weighted regression (GWR) were used to explore statistical and spatial associations. Results: The municipalities in Colombia with Higher mortality tend to have lower geographical accessibility to obstetric and neonatal beds after controlling the fertility and economic characteristics of these municipalities. This association is significant only in municipalities of the west coast. The strength of this association decreases in inner municipalities. Discussion: The centralization of obstetric and neonatal beds in major municipalities around the central region leaves municipalities with high risk of mortality underserved. The decentralization of obstetric and neonatal healthcare resources is a mandatory issue in order to reduce geographical disparities in mortality and to improve neonatal survival, and a healthy beginning of life...(AU)

Introducción: La distribución de los recursos de salud influencia la mortalidad neonatal temprana, garantizar el acceso atención obstétrica es un problema de salud pública. Sin embargo, la dimensión geográfica de esta influencia no ha sido estudiada en Colombia. Objetivo: Describir la accesibilidad geográfica a camas obstétricas y neonatales y su asociación con la mortalidad neonatal temprana en Colombia por municipios. Método: Se realizó un estudio ecológico a nivel municipal. Se recurrió a regresión por mínimos cuadrados y a regresión geográficamente ponderada para explorar las asociaciones estadísticas y espaciales. Resultados: Municipios con mayores tasas de mortalidad tienden a mostrar menor accesibilidad geográfica a camas obstétricas y neonatales, después de controlar las características municipales, económicas y de fecundidad. Esta asociación solo es significativa en municipios de la costa oeste. La fuerza de la asociación disminuye en municipios del interior. Discusión: Centralizar las camas obstétricas y neonatales en ciudades principales de la región central deja desatendidos a los municipios con mayor mortalidad. La descentralización de recursos de cuidado obstétrico y neonatal es un asunto obligatorio para reducir desigualdades geográficas en mortalidad, aumentar la supervivencia neonatal y lograr un inicio de vida saludable...(AU)

Introdução: A distribuição dos recursos da saúde tem influência na mortalidade precoce do neonatal, garantir o acesso aos cuidados obstétricos é um problema da saúde pública. A pesar de que, a dimensão geográfica desta influência não foi estudada na Colômbia. Objetivo: Descrever a acessibilidade geográfica aos leitos obstétricos e neonatos e, a sua associação com a mortalidade neonatal precoce na Colômbia, nos municípios. Método: O estudo ecológico foi realizado nos municípios. A regressão de mínimos quadrados e a regressão geograficamente ponderada foram utilizadas para explorar as associações estatísticas e espaciais. Resultados: Os municípios com taxas de mortalidade mais elevadas tendem a mostrar menor acessibilidade geográfica aos leitos obstétricos e neonatos após o controle das características municipais, econômicas e da fertilidade. Esta associação é apenas significativa nos municípios do litoral oeste. A força da associação diminui nos municípios do interior. Discussão: A centralização de camas obstétricas e neonatas nas principais cidades da região central, deixa os municípios não atendidos com a maior taxa de mortalidade. A descentralização dos recursos dos cuidados obstétricos e neonatos é uma questão obrigatória para reduzir as desigualdades geográficas na mortalidade, aumentar a sobrevivência neonatal e alcançar um bom início de vida saudável...(AU)

Entendendo a necessidade de médicos no interior da Amazônia - Brasil / Understanding the need for doctors in innerstate Amazon - Brazil

Um dos dilemas atuais do setor saúde no mundo é a má distribuição de médicos entre áreas rurais e urbanas, e entre capitais e interior. No Brasil, a Região Norte é a que possui a menor quantidade de médicos por habitantes. O objetivo deste estudo foi analisar os indicadores de distribuição de médicos na Região Norte, com especial atenção para as disparidades entre capitais e interior. Trata-se de um estudo ecológico, cujas fontes consultadas foram os bancos de dados ou documentos oficiais do IBGE, CFM e ANS. O principal indicador utilizado foi a relação de médicos por mil habitantes. A Região Norte possui um médico por mil habitantes. O conjunto de capitais possui 2,5, variando de 1,4 em Macapá a 3,4 em Belém. O interior da Amazônia possui 0,4, variando de 0,2 no Amazonas a 1,1 no Tocantins. O acesso a médicos nas capitais chega a ser mais de dez vezes superior no Amazonas e no Pará em relação ao interior. O local que mais necessita de médicos no Brasil é o interior da Amazônia.

One of the current dilemmas inhealthcare worldwideis the unequal distribution of doctors between rural and urban areas, and capital cities and smaller towns. The north of Brazil is the region with lowest number of doctors per capita. The aim of this study is to analyze the indicators of physician distribution in the north of Brazil, focusing especially on disparities between capital cities and smaller towns. This ecological study draws on official statistics and documents of Brazilian institutions.Themain indicator used was the ratio of doctors per one thousand inhabitants. The nothern region has one doctor per one thousand inhabitants. The number in the set of capital cities was 2.5, ranging from 1.4 in Macapa to 3.4 in Belem. In innerstateregions of the Amazonthe figure was 0.4, ranging from 0.2 in Amazonas to 1.1 in Tocantins. Access to doctors in the capital cities of Amazonas and Paráis more than ten times greater than outside the capitals. This is the region of Brazil that is most in need of doctors.

A 10-year analysis of metastatic prostate cancer as an initial presentation in an underserved population

Objective To analyze patients from an underserved area who presented initially with metastatic prostate cancer in order to identify patients in our population who would suffer greatly if PSA screening was eliminated. Materials and Methods A prospectively maintained androgen deprivation therapy database from an inner city municipal hospital was queried to identify patients who presented with metastatic prostate cancer. We identified 129 individuals from 1999 to 2009 eligible for study. Those who underwent previous treatment for prostate cancer were excluded. We examined metastatic distribution and analyzed survival using Kaplan Meier probability curves. Results The median age of presentation was 68 with a median Gleason sum of 8 per prostate biopsy. Thirty-two patients presented with hydronephrosis with a median creatinine of 1.79, two of whom required emergent dialysis. Of those patients who underwent radiographic imaging at presentation, 35.5% (33/93) had lymphadenopathy suspicious for metastasis, 16.1% (15/93) had masses suspicious for visceral metastases. Of the patients who underwent a bone scan 93% (118/127) had positive findings with 7.9% (10/127) exhibiting signs of cord compression. The 2 and 5- year cancer specific survival was 92.1% and 65.6%, respectively. Conclusions In this study we have highlighted a group of men in an underserved community who presented with aggressive and morbid PCa despite widespread acceptance of PSA screening. .