Thesis (M.P.H.M. (Primary Health Care Management))--Mahidol University, 2008. / LICL has E-Thesis 0038 ; please contact computer services.

Submitted by MARCIA ROVADOSCHI (marciar@unifra.br) on 2018-08-22T13:40:02Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_HeloisaAtaideIsaia.pdf: 1912361 bytes, checksum: 797eb0d92644ff00810ab6bfb75143ef (MD5) / Made available in DSpace on 2018-08-22T13:40:02Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_HeloisaAtaideIsaia.pdf: 1912361 bytes, checksum: 797eb0d92644ff00810ab6bfb75143ef (MD5) Previous issue date: 2017-06-16 / Obesity in children and adolescents is worrisome because of its increasing prevalence and risk of associated chronic diseases, with unpostponable preventive and treatment actions. This study aimed to analyze aspects of anthropometry, blood pressure, and laboratory tests at the initial consultation and its evolution in follow-up consultations and to develop a booklet for recommendations and approaches to obesity in primary care. This study collected data from medical records (age, sex, origin, weight, height, blood pressure, laboratory tests) of a cohort of overweight children and adolescents of both sexes between the ages of 2 and 19 that were seen at a specialized outpatient clinic of a tertiary hospital between May 2013 and May 2016. Children were considered to be those younger than 10 years of age. In the initial consultation, 194 patients (51% children) were assessed and 146 patients participated in the follow-up consultation. In the initial consultation, body mass index (BMI), z-score and waist circumference (AC) were significantly higher in adolescents, with severe obesity being more prevalent in children (16.2%). There was no difference between children and adolescents in the mean systolic / diastolic blood pressure percentile. Of the laboratory tests, the only statistically significant difference was the increased total cholesterol level in 48.7% of the adolescents compared with 27% of the children, but HDL was decreased in both. In the follow-up the participants had an average of 5.3 (± 3.4) visits. They showed gains in weight, height and waist circumference. There was a significant decrease in the BMI z-score. There was a decrease in the systolic / diastolic blood pressure percentile, as well as the percentage of patients with abdominal circumference greater than the 90th percentile. The desirable levels of triglycerides, total cholesterol, LDL, and HDL increased significantly between the two evaluations, although 47.4% of the patients still maintained HDL below the desirable level. It was concluded that outpatient follow-up of obese children and adolescents and their families was shown to be positive, at least in the short term, with a reduction of risk factors for cardiovascular diseases, since there was a decrease in waist circumference, tendency for hypertension, hypercholesterolemia and low HDL. As a proposal for prevention and approach to obesity in primary care, the guideline leaflet can contribute. However, when obesity is already established, the specialized service has been shown to be important. It is necessary to evaluate the service offered for more effective actions also in the long term. / A obesidade nas crianças e adolescentes preocupa em razão de sua crescente prevalência e risco de doenças crônicas associadas, sendo as ações preventivas e de tratamento inadiáveis. Este estudo teve como objetivo analisar aspectos de antropometria, pressão arterial e de exames laboratoriais na consulta inicial e sua evolução em consulta de seguimento e desenvolver um folheto para recomendações e abordagem da obesidade na atenção primária. Trata-se de estudo retrospectivo, de coleta de dados de prontuários (idade, sexo, procedência, peso, estatura, pressão arterial, exames laboratoriais), de uma coorte de crianças e adolescentes com excesso de peso, de ambos os sexos, de 2 a 19 anos de idadeeatendidos em ambulatório especializado de um hospital terciário, no período de maio de 2013 a maio de 2016. Foram consideradas crianças os com idade menor que 10 anos.Na consulta inicial foram avaliados 194 pacientes (51% crianças) e na consulta subseqüente 146 pacientes que mantiveram o acompanhamento.Na consulta inicial o índice de massa corporal (IMC), z-score e circunferência abdominal (CA) foram significativamente maiores nos adolescentes, sendo a obesidade grave mais prevalente nas crianças (16,2%). Não houve diferença entre as crianças e adolescentes na média do percentil da pressão arterial sistólica/diastólica.Dos exames laboratoriais, o único com diferença estatística foi o nível aumentado de colesterol total em 48,7% dos adolescentes contra 27% das crianças, mas o HDL encontrava-se diminuído em ambos.No acompanhamento os participantes tiveram em média 5,3(±3,4) consultas, aumento do peso, estatura e circunferência abdominal e diminuição significante da média do z-score do IMC.Houve queda do percentil da pressão arterial sistólica/diastólica, bem como o percentual de pacientes que apresentavam circunferência abdominal maior que o percentil 90.Os níveis desejáveis dos triglicerídeos, colesterol total, LDL, HDL aumentaram significativamente entre as duas avaliações, embora 47,4% dos pacientes ainda mantivessem o HDL abaixo do nível desejável.Conclui-se que o acompanhamento ambulatorial de crianças e adolescentes obesos e suas famílias, mostrou-se positivo, pelo menos em curto prazo, com redução dos fatores de riscopara doenças cardiovasculares, uma vez que houve diminuição da circunferência abdominal, tendência a hipertensão, hipercolesterolemia e HDL baixo.Como proposta para prevenção e abordagem da obesidade na atenção primária o folheto orientador pode contribuir, mas quando a obesidade já estiver estabelecida o serviço especializado mostra-se importante. Ressalta-se a necessidade de avaliação do serviço oferecido visando ações mais efetivas também em longo prazo.

As complicações de pacientes com insuficiência renal crônica submetidos ao tratamento hemodialítico representam desafios para os profissionais de saúde. A variabilidade de fatores de risco que predispõem a essas complicações têm sido, freqüentemente, investigada na literatura científica. Nesse sentido, objetivou-se descrever as complicações locais e sistêmicas dos pacientes com insuficiência renal crônica a partir da implantação do cateter temporário de duplo lúmen para hemodiálise até sua retirada definitiva. Trata-se de um estudo de segmento que avaliou prospectivamente os pacientes da implantação do cateter até sua retirada definitiva. Para o estabelecimento do grupo estudado foi considerado um período de seis meses consecutivos de julho a dezembro de 2003. Assim, após a aprovação do Comitê de Ética em pesquisa procedeu-se a coleta dos dados. Para análise dos resultados realizou-se a codificação das variáveis no banco de dados do programa Microsoft Excel mediante dupla digitação, e, utilizou-se o programa Software Statistical Package for Social Sciences, versão 10.0 na análise estatística. Dos 64 pacientes avaliados 38 (59,4%) eram do sexo masculino, 20 (31,2%) tinham como causa provável da insuficiência renal a nefroesclerose hipertensiva, e, 35 (54,7%) implantaram o cateter devido à necessidade do tratamento hemodialítico imediato. Totalizou-se no período 145 cateteres implantados, 29 (45,3%) dos pacientes tiveram implantes únicos, 98 (67,6%) dos acessos foram a veia jugular interna direita, 40 (27,6%) das trocas dos cateteres foram devido a febre. O tempo médio de permanência dos cateteres foi de 30 dias. A complicação local mais freqüente em 41 (64%) dos pacientes foi o funcionamento inadequado do cateter com 26 dias de média para a ocorrência, e, a complicação sistêmica mais freqüente em 24 (37,5%) foi a febre com 34 dias de média para sua ocorrência, 27 (42,2%) dos pacientes apresentaram infecção do sítio de inserção, e, 30 (47%) infecção da corrente sanguínea. O Staphylococcus aureus foi o microrganismo mais isolado em 10 (33,4%) das hemoculturas. Observou-se que 45 (70,4%) dos pacientes retiraram definitivamente o cateter devido à punção da fístula arteriovenosa. O estudo apontou aspectos preocupantes, dentre eles, o tempo de permanência do cateter, que expõe sobremaneira o paciente a diferentes complicações, em especial, a infecção. A confecção da fístula arteriovenosa representa uma importante alternativa que contrapõe o uso do cateter temporário. / Complications in chronic renal insufficiency patients under dialysis treatment represent important challenges to health professionals. The variety of risk factors predisposing towards these complications have frequently been discussed in scientific literature. Thus, this study aimed to describe the local and systemic complications of chronic renal insufficiency patients who were using a temporary double-lumen catheter for hemodialysis treatment, until its final withdrawal. A segment research prospectively studied patients from the moment the catheter was inserted until its final withdrawal. A period of six consecutive months, from July to December 2003, was considered to determine the group of patients ti be studied. Thus, after ethical approval, data were collected through interviews, clinical exams and patient record evaluation. For the result analysis, the variables were coded in a database through double data entry in Microsoft Excel and Software Statistical Package Social Sciences, version 10.0 was used for statistical analysis. 38 (59.4%) of the 64 patients were men, 20 (31.2%) showed hypertensive nephrosclerosis as the probable cause of insufficiency renal and 35 (54.7%) inserted the catheter due to the need for immediate hemodialysis treatment. 145 catheters were inserted during the period, 29 (45.3%) of which were single implants and the right internal jugular vein was the access in 98 cases (67.6%). Average catheter permanence time was 30 days. Catheters were substituted in 40 cases (27.6%) due to fever. The most frequent local complication was inadequate functioning in 41 (64%) cases, with an average occurrence of 26 days, while the most frequent systemic complication was fever in 24 cases (37.5%), with an average occurrence of 34 days. Infection of the insertion site occurred in 27 (42.2%) cases and infection of the blood flow associated with the catheter in 30 (49%) cases. Sthaphylococos aureus was the most frequently isolated microorganism in 10 (33.4%) blood cultures. 45 (70.4%) final catheter withdrawals were due to arterio-venous fistula puncture. This analysis revealed various preoccupying aspects, including the catheter permanence time, which highly exposes the patient to different complications, particularly infection.

Bakgrund: I Sverige utreds patienter med misstänkt cancer enligt Standardiserat Vårdförlopp. Det involverar många vårdgivare och professioner och kan vara en utmaning när det gäller personcentrerad vård. För patienter som utreds för matstrups- eller magsäckscancer innebär deras första SVF-besök i specialistvården en gastroskopi och mottagningsbesök. SVF-förloppet är en relativt ny vårdform och det finns inte så mycket beskrivet om patientens erfarenhet i litteraturen.   Syfte: Syftet med studien är att undersöka patienters erfarenhet av det första besöket inom den kirurgiska öppenvården hos patienter med matstrups- eller magsäckscancer inom SVF-förloppet som har en kurativ intention på deras behandling.   Metod: En kvalitativ intervjustudie med induktiv ansats genomfördes för att besvara studiens syfte. Nio intervjuer har analyserats med tematisk analys.   Resultat: Den tematiska analysen resulterade två tema, ”visshet/vetskap skapar hanterbarhet” samt ”stöd och kompetens lugnar”.   Konklusion: Många aspekter spelar roll för patientens erfarenhet av besöket. Patientens tidigare erfarenheter påverkar hur deras vård i samband med första besöket upplevs. Information ska anpassas efter patienten. Anhöriga bör inkluderas vid besöket då de kan vara en viktig resurs för patienten. Sjuksköterskan bör arbeta personcentrerat, vara stödjande och kompetent samt skapa trygghet. Specialistsjuksköterskan spelar en viktig roll genom att bedöma och handlägga komplexa omvårdnadssituationer, leda och deltaga i forskning och förbättringsarbete. / Background: In Sweden, patients with suspected Oesophageal or Gastric cancerare evaluated accordingto a dedicated care bundle named Standardized Pathways protocol that includes both medical evaluations and information from different health careproviders. The first visitat the ambulatory care includes an upper GI endoscopy performed by the upper GI surgeon and a consultation with a highly specialized team.The whole process can be a challenge for the patient when it comes to patient-centredcare. This way of directing patients with suspicion of cancer is a relatively newform of care and and there are few reports describing the patient’s experience. Purpose: The purpose of the study is to investigate patients' experience of the first visit to the surgical ambulatory care of patients with Oesophageal or Gastric cancer within the Standardized pathwaysand has a curative treatmentplan. Method: A qualitative interview study with inductive approach was conducted to answer the purpose of the study. Nine interviews were analyzed using thematic analysis. Results: The thematic analysis resulted in two themes, “knowledge makes manageability” and “support and competence calms”. Conclusion: Many aspects matter in the patient's experience of the visit. The patient's past experiences affect how they perceive their care in connection with Standardized pathways. Information should be adapted to the patient. Relatives should be included during the visit as they can be an important resource for the patient. The nurse should work patient-centred, be supportive and competent, and make the patient feelsecure. The specialist nurse plays an important role by assessing and managing complex nursing situations, leading and participating in research and improvement.

La demanda generada por pacientes con patologías oncológicas se ha incrementado a medida del incremento de la incidencia de casos. Esto, sumado al requerimiento de atención médica intradomiciliaria debido a la pandemia por el virus SARS-COV-2, genera una necesidad, así como una oportunidad de negocio. El presente trabajo desarrolla el Plan de Negocios Cuidándote, que presta servicios de cuidados paliativos a domicilio para pacientes con diagnóstico oncológico en estadio IV, afiliados a una IAFAS privada y residentes en Lima Metropolitana. La demanda insatisfecha existente será atendida empleando la estrategia de Diferenciación. La propuesta de valor es prestar servicios de cuidado integral al binomio paciente - familia, cuyo objetivo es mejorar la calidad de vida del paciente y brindar soporte tanto educativo como emocional que la familia necesita, con la colaboración de un equipo multidisciplinario especializado en cuidados paliativos y manejo del dolor. El modelo de negocio está basado en contratos con IAFAS privadas, teniendo un mercado potencial de tres IAFAS con un total de 130,271 afiliados, proyectándose la venta de un total de 360 paquetes para el primer año. El capital es de S/. 500,000.00 soles, 50% es un préstamo bancario y el otro 50% es inversión de los accionistas, destinando el 13% a costos fijos totales anuales y el 87% a costos variables anuales. El proyecto tiene una VANE de S/.430,466 soles y un TIR económico de 37% y un TIRF de 45%, lo cual indica que es viable para su ejecución y los riesgos son controlables. / The demand generated by patients with oncological pathologies has increased as the incidence of cases has increased. This, added to the requirement for home health care due to the SARS-COV-2 virus pandemic, creates a need, as well as a business opportunity. This work develops the Cuidándote Business Plan, which provides palliative care services at home for patients with stage IV cancer diagnosis, affiliated with a private IAFAS and residents of Metropolitan Lima. The existing unsatisfied demand will be met using the Differentiation strategy. The value proposition is to provide comprehensive care services to the patient - family binomial, whose objective is to improve the quality of life of the patient and provide both educational and emotional support that the family needs, with the collaboration of a multidisciplinary team specialized in palliative care and pain management. The business model is based on contracts with private IAFAS, having a potential market of three IAFAS with a total of 130,271 affiliates, projecting the sale of a total of 360 packages for the first year. The capital is S /. 500,000.00 soles, 50% is a bank loan and the other 50% is investment by the shareholders, allocating 13% to total annual fixed costs and 87% to annual variable costs. The project has an NPV of S /.430,466 soles and an economic IRR of 37% and an IRR of 45%, which indicates that it is viable for its execution and the risks are controllable. / Trabajo de investigación

Serious mental illness (SMI) affects 5% of the United States population and is associated with increased morbidity and mortality. Use of high-cost healthcare services is common, including hospitalizations and emergency department (ED) visits. Integrating behavioral and physical healthcare may improve care for consumers with SMI, but prior research findings have been mixed. This quantitative retrospective cohort study addressed the impact of integrated care on physical health and ambulatory care sensitive (ACS) utilization via a program evaluation of an integrated health clinic (IHC) at a community mental health center (CMHC). The research questions assessed whether there was a predictive relationship between IHC enrollment and physical health and ACS-specific service utilization for consumers with SMI when controlling for demographic characteristics and disease severity. Secondary administrative healthcare data, including authorization and electronic medical record data, were provided by the CMHC. Logistic regressions assessed the odds of experiencing an inpatient admission or ED visit before or after IHC enrollment; the predictive relationship between IHC enrollment and service utilization was assessed using multiple linear and Poisson regression analyses. There was no statistically significant impact of integrated care clinic enrollment on physical health or ACS-specific utilization. The sample had lower levels of physical health utilization than would have been expected. In terms of positive social change, results may help the CMHC assess the IHC program, overall clinic success, and use of data. Since policy and payment structures continue to support integrated care models, further research on different programs are encouraged, as each setting and practice pattern is unique.

No description available.

<p>Zbog visoke stope morbiditeta i mortaliteta od kardiovaskularnih bolesti, udeo lekova za terapiju kardiovaskularnih bolesti značajno učestvuje u ukupno utro&scaron;enoj količini lekova u svetu. Evidentan je porast potro&scaron;nje lekova za kardiovaskularne bolesti. Radi postizanja &scaron;to je moguće vi&scaron;eg stepena racionalizacije terapije u većini zemalja stručna tela donose farmakoterapijske smernice kako bi se mogućnost pogre&scaron;nog lečenja svela na najmanju moguću meru. Na ovaj način lekaru-praktičaru pružena je sigurnost pravilnog izbora i najadekvatnijeg postupka u datim okolnostima. Ciljevi ovog istraživanja bili su: 1) izračunavanje ukupne vanbolničke potro&scaron;nje lekova za lečenje kardiovaskularnih bolesti na teritoriji Novog Sada i njeno poređenje sa propisivanjem u Republici Srbiji i u zemljama sa razvijenom farmakoterapijskom praksom; 2) analiza strukture propisanih lekova za lečenje kardiovaskularnih bolesti (grupa C prema ATC klasifikaciji) po grupama i njeno poređenje sa propisivanjem u Republici Srbiji i u zemljama sa razvijenom farmakoterapijskom praksom; 3) analiza strukture propisanih lekova po dijagnozama i provera usklađenosti sa farmakoterapijskim smernicama; 4) komparacija propisanih lekova sa morbiditetnom statistikom kardiovaskularnih bolesti; 5) analiza farmakoekonomskih aspekata propisivanja lekova za kardiovaskularne bolesti. Sprovedeno istraživanje spada u IV fazu kliničkih ispitivanja-farmakoepidemiolo&scaron;ko, retrospektivno, opservaciono. Podaci su prikupljeni na osnovu izve&scaron;taja iz elektronske baze podataka za period od 6 meseci (01. 01. 2012 &minus; 01. 07. 2012), na teritoriji grada Novog Sada. Na osnovu ovih podataka na teritoriji grada Novog Sada analizirana je upotreba lekova za kardiovaskularne bolesti na 100% uzorku stanovnika. Ispitivanje se sastojalo iz dva dela. Prvi deo obuhvata prikupljanje, obradu i analizu podataka o ukupno propisanoj količni lekova za kardiovaskularne bolesti na teritoriji grada Novog Sada. U drugom delu istraživanja kori&scaron;ćenjem podataka dobijenih iz državne &bdquo;Apoteke Novi Sad&ldquo; detaljnije je analizirana upotreba lekova za lečenje kardiovaskularnih bolesti izdatih na recept. Upotreba lekova analizirana je: prema uzrastu i polu pacijenata, prema dijagnozama za koje su lekovi propisani i prema ceni. Sruktura upotrebe lekova po indikacijama za dijagnoze kod kojih je ukupna upotreba propisanih lekova bila veća od 1 DDD/1000stanovnika/dan upoređena je sa postojećim nacionalnim vodičima i sa upotrebom u zemljama sa razvijenom farmakoterapijskom praksom, odnosno sa međunarodnim vodičima. Ovi podaci upoređeni su sa morbiditetnom statistikom na teritoriji grada Novog Sada. Ukupno propisana količina lekova za kardiovaskularne bolesti u posmatranom periodu iznosila je 399,79 DDD/1000st/dan. Od te količine, preko polovine (201,11DDD/1000st/dan) propisivanih lekova za kardiovaskularne bolesti su lekovi koji deluju na sistem renin-angiotenzin, slede blokatori kalcijumskih kanala, zatim blokatori beta-adrenergičkih receptora, a na četvrtom mestu po ukupno propisanoj količini su lekovi za terapiju bolesti srca. Od najče&scaron;ćih dijagnoza za koje su propisivani lekovi za kardiovaskularne bolesti, najzastupljenije su bile arterijska hipertenzija, a potom ishemijska bolest srca. Upotreba lekova za kardiovaskularne bolesti u vanbolničkoj sredini na teritoriji grada Novog Sada (399,79 DDD/1000st/dan) vi&scaron;a je u odnosu na zemlje u okruženju (Hrvatsku, Crnu Goru), a niža u odnosu na zemlje sa razvijenom farmakoterapijskom praksom. U odnosu na zemlje sa razvijenom farmakoterapijskom praksom postoje odstupanja u pogledu strukture propisivanja. Struktura propisivanja lekova za kardiovaskularne bolesti odstupa od važećih nacionalnih vodiča o racionalnoj upotrebi lekova za kardiovaskularne bolesti u Republici Srbiji. Istovremeno struktura propisanih lekova nije u skladu sa morbiditetnom statistikom kardiovaskularnih bolesti prema zvaničnim podacima. Među 10 najče&scaron;će propisanih lekova nalaze se i skupi lekovi, koji imaju adekvatne, a mnogo jeftinije paralele. Nedovoljno i neracionalno lečenje kardiovaskularnih bolesti verovatno su jedan od značajnih razloga za visoku smrtnost od kardiovaskularnih bolesti u Srbiji.</p> / <p>Due to high rates of morbidity and mortality from cardiovascular diseases, the share drugs for the treatment of cardiovascular diseases significantly contributes to a total utilization among drugs in the world. There is an evident increase in the consumption of drugs for cardiovascular diseases. In order to achieve as much as possible a higher level of rationalization of therapy in most countries the professional bodies making pharmacotherapeutic guidelines to the possibility of the wrong treatment was reduced to a minimum. In this way, the physician-practitioner provided the security proper selection and the most appropriate procedure in the circumstances. The objectives of this study were: 1) the calculation of the total outpatient consumption of drugs for the treatment of cardiovascular diseases on the territory of Novi Sad and its comparison with the prescribing in the Republic of Serbia and the countries with developed pharmacotherapeutical practice; 2) analysis of the structure of prescribed drugs for the treatment of cardiovascular diseases (group C according to the ATC classification) by the groups and its comparison with the prescribing in the Republic of Serbia and the countries with developed pharmacotherapeutical practice 3) analysis of the structure of prescribed drugs per diagnosis and verification of compliance with pharmacotherapeutic guidelines; 4) comparison of prescribed drugs with morbidity statistics cardiovascular diseases; 5) analysis of pharmacoeconomic aspects of prescribing drugs for cardiovascular diseases. A research conducted among the phase IV clinical trials-pharmacoepidemiological, retrospective observational. Data were collected on the basis of a report from the electronic database for the period of 6 months (01. 01. 2012 - 01. 07. 2012), on the territory of the city of Novi Sad. Based on these data on the territory of the city of Novi Sad analyzed the use of drugs for cardiovascular diseases at 100% sample of the population. The research consisted of two parts. The first part comprises the collection, processing and analysis of data on the total quantity of the prescribed cardiovascular drugs on the territory of the city of Novi Sad. In the second part of this research using data from the public &quot;Pharmacy Novi Sad&quot; is a more detailed analysis of the utilization of drugs for the treatment of cardiovascular diseases of prescription. The utilization of drugs is analyzed: according to the age and sex of patients, in diagnosis for which the drugs prescribed and to the cost. Structure of the use of drugs by indications for diagnosis in which the total utilization of prescribed drugs was greater than 1 DDD/1000inhabitants/day was compared with the existing national guidelines and use in countries with developed pharmacotherapeutical practice, and with international guidelines. These data were compared with morbidity statistics on the territory of the city of Novi Sad. Total amount of prescribed drugs for cardiovascular diseases in the examined period was 399.79 DDD/1000inh/day. Of this amount, more than half (201.11 DDD/1000inh/day) were drugs acting on the renin-angiotensin system, followed by calcium channel blockers, beta adrenergic receptor blockers, and fourth in total prescribed quantity drugs for treatment of heart diseases. Of the most common diagnosis for which drugs for cardiovascular diseases were prescribed, the most common were arterial hypertension, and then ischemic heart disease. The use of drugs for cardiovascular diseases in outpatient environment on the territory of the city of Novi Sad (399.79 DDD/1000inh/day) is higher compared to neighboring countries (Croatia, Montenegro), and lower than in countries with developed pharmacotherapeutical practice. Compared to countries with developed pharmacotherapeutical practice there are variations in terms of the structure of prescribing. Structure of prescribing of drugs for cardiovascular diseases deviates from the existing national guidelines on rational use of drugs for cardiovascular diseases in the Republic of Serbia. At the same time the structure of prescribed drugs is not in compliance with morbidity statistics cardiovascular diseases according to official data. Among the 10 most commonly prescribed drugs are costly drugs, that have adequate, and much cheaper parallels. Insufficient and irrational treatment of cardiovascular diseases are probably one of the major reasons for the high mortality from cardiovascular diseases in Serbia.</p>

O absenteísmo, ou seja, a falha no atendimento (FA) ou não atendimento (NA) dos usuários nos serviços de saúde do Sistema Único de Saúde (SUS) é um assunto de crescente interesse devido ao grande número de pessoas aguardando atendimento e ao contexto econômico atual. A problemática acarreta prejuízos a todos envolvidos, pois prolonga a conclusão diagnóstica, prejudica o tratamento, diminui a produtividade do prestador, causa aumento de tempo na espera por atendimento dos demais usuários e desperdício de recursos públicos. Portanto, o objetivo deste estudo foi compreender os motivos do absenteísmo nos serviços de saúde e as estratégias praticadas para a redução de falhas no atendimento. Trata-se de pesquisa qualitativa, com desenho de estudo de caso descritivo-exploratório, baseado em entrevistas semi-estruturadas e grupo focal. A coleta de dados visou a identificar diferentes opiniões e explicações para o absenteísmo, as estratégias e perspectivas utilizadas pelas equipes de saúde da AME e das secretarias de saúde de quatro municípios. Foram selecionados quatro casos traçadores para evidenciar experiências típicas, ou seja, dois municípios que pudessem demonstrar uma dinâmica mais exitosa no controle do absenteísmo e outros dois representantes de experiências menos exitosas. A análise permitiu representar o perfil dos serviços locais \"em situação\", discutindo estratégias, processos de trabalho, facilidades e dificuldades. Foi possível evidenciar as diferentes características e fluxos nos quatro municípios estudados, bem como a pequena ou inexistente discussão sobre o absenteísmo. Durante as entrevistas, nenhum dos entrevistados sabia ao certo a taxa de falha de atendimento e demonstraram-se surpresos quando informados de que são em média 560 consultas especializadas perdidas por mês. Todos concordaram que devem ser adotadas estratégias de prevenção ao absenteísmo, e, principalmente, esses dados devem ser divulgados à população. Concordaram ainda que outros setores podem e devem ser copartícipes na efetivação de uma rede local de atenção à saúde, no registro do fluxo dos usuários, utilizando diferentes espaços para a promoção da frequência ao atendimento e educação em saúde. Foram compartilhadas várias estratégias e propostas de mudança para reorganização municipal e alteração nos fluxos de trabalho, bem como comunicação entre os serviços e os usuários. Este estudo proporcionou a oportunidade de discussão entre os envolvidos no processo de acesso aos serviços de saúde do AME Araçatuba. Permitiu a reflexão sobre responsabilidades e papéis dos atores no processo. O folder produzido a partir desta pesquisa e apoiado pela revisão bibliográfica será utilizado na capacitação de profissionais, com a finalidade de subsidiar o planejamento em saúde e melhorar a assistência proposta ao usuário do SUS. / Absenteeism, that is, the non-attendance of users in health services of Unified Health System is a subject of growing interest due to large number of people waiting for care and current economic context. The problem entails damages to all involved, since it prolongs the diagnostic conclusion, impairs the treatment, decreases the provider\'s productivity, causes an increase in waiting time for other users\' attention, and wastage of public resources. Therefore, the aim in this study was to understand the reasons for absenteeism in health services and the strategies used to reduce service failures. It is qualitative research, in the design of the case study, descriptive-exploratory based on interstructure interviews and focal group. The interview is a technique of collecting data through group interactions, mediated by a facilitator, to encourage the formation of opinions on the absenteeism, strategies and perspectives of the health teams. Four tracer cases were selected to show typical experiences, that is, two municipalities that could demonstrate the most successful dynamics in control of absenteeism and two other less successful representatives of the same. The analysis allowed to represent the profile of local services \"in situation\", discussing strategies, work processes, facilities, and difficulties. It was possible to show the different characteristics and flows between the four municipalities studied and how little or no discussion about absenteeism is available. During the interview, none of municipalities interviewed knew for certain that the rate of service failure was surprising when informed that they are on average 560 specialized consultations lost per month. All agreed that strategies should be taken, and especially, these data should be made public. They also agree that other sectors can and should be partners in the implementation of the local health care network, in execution of flow users, use of other spaces for awareness, and education in health. Several strategies and proposals for change have been shared for municipal reorganization and changes in workflows and communication between services and users. This study provided the opportunity for discussion among those involved in the process of access to the health services of Ambulatory Care of Araçatuba. It allowed for reflection on the responsibilities and roles of actors in the process. The folder produced from this research and supported by bibliographic review will be used to train professionals, with the purpose of subsidizing health planning and improving the proposed assistance to Unified Health System users.

Introdução: O atendimento à saúde da mulher no Sistema Único de Saúde (SUS) tem sido realizado nos diferentes níveis de atenção à saúde e a abordagem terapêutica das principais doenças ginecológicas não oncológicas dependem das características dos equipamentos disponíveis nas redes de atenção à saúde do SUS. A associação entre diagnósticos ginecológicos e sua distribuição nos setores de saúde proporcionam benefícios no campo da prevenção e promoção das doenças, na educação médica e interdisciplinar, além de racionalização de recursos de acordo com o nível de complexidade assistencial. Objetivo: Avaliar a correlação dos diagnósticos não oncológicos em saúde de mulheres referenciadas e sua distribuição nos níveis de atenção à saúde. Método: Trata-se de estudo transversal e analítico a partir de 428 prontuários de mulheres atendidas em Ambulatório Universitário de Saúde da Mulher, de referência em ginecologia e de treinamento para Residentes de Medicina de Família e Comunidade, São Paulo - Brasil, entre 2012 - 2014. Foram descritas informações clínico demográficas, diagnósticos ginecológicos (Classificação Internacional das Doenças - 10a versão) e distribuição dos serviços de saúde (primário, secundário e terciário). Na análise estatística, foram descritas medidas de tendência central e dispersão. O teste Qui-quadrado foi utilizado para variáveis qualitativas e Risco Relativo Bruto para a proporção de diagnóstico de ginecologia em relação à distribuição de setores de saúde e intervalo de confiança de 95. Resultados: Verificou-se que as mulheres tinham idade entre 13 a 94 anos, eram provenientes principalmente da UBS Jardim São Jorge 39,72% (n = 170), com mediana etária da menarca de 13 anos (Intervalo interquartil 12 a 14 anos), início da atividade sexual aos 18 anos (Intervalo interquartil 16 a 20 anos) e menopausa aos 50 anos (Intervalo interquartil 45 a 53 anos). Em relação à presença de doenças concomitantes, 17,78% (n = 72) apresentaram duas ou mais morbidades associadas. Os principais diagnósticos não oncológicos observados na população total do estudo foram os transtornos não inflamatórios do trato genital feminino 70,10% (n = 300) e as doenças do aparelho urinário 18,22% (n= 78). As chances de ter doenças da mama e transtornos não inflamatórios do trato genital feminino durante o período reprodutivo correspondem a 3,61 (IC 1,00-16,29) e 2,56 vezes (IC 1,00-4,16) maior, respectivamente, do que a chance de ter essa doença no período não reprodutivo (p < 0,001). Conclusão: Os principais diagnósticos não oncológicos em ginecologia são transtornos não inflamatórios do trato genital feminino (N80-99) e doenças do aparelho urinário (N30-N39). Doenças do aparelho urinário (N30-N39), exame geral, contracepção e procriação (Z00-31) foram os diagnósticos que permaneceram entre os setores primário e secundário / Introduction: Women\'s healthcare in Unified Health System (SUS) has been performed in different levels of healthcare, and the therapeutic approach of the main non-oncological gynecological diseases depend on the equipment characteristics available in SUS healthcare networks. The association between gynecological diagnoses and their distribution in health sectors provides benefits in prevention and promotion diseases area, in medical and interdisciplinary education, and rationalization of resources according to the level of care complexity. Objective: To assess the correlation of non-oncological diagnoses in health of referenced women and their distribution in healthcare levels. Methods: This is a cross-sectional and analytical study based on 428 medical records of women attending a University Outpatient Clinic for Women\'s Health, a reference in gynecology and training for Residents of Family and Community Medicine, São Paulo, Brazil, from 2012 to 2014. Clinical-demographic data, gynecological diagnoses (International Classification of Diseases - 10th version) and distribution of health services (primary, secondary and tertiary) have been described. In statistical analysis, measures of central tendency and dispersion were described. The Chi-square test was used for qualitative variables and Gross Relative Risk for the proportion of gynecological diagnosis in relation to the distribution of health sectors and confidence interval of 95%. Results: It was verified that 13 to 94 years old women, mainly from UBS Jardim São Jorge, 39.72% (n = 170) with median age of menarche of 13 years old (interquartile range 12 to 14 years old), sexual onset at 18 years old (interquartile Interval 16 to 20 years old) and menopause at 50 years old (interquartile Interval 45 to 53 years old). Regarding the presence of concomitant diseases, 17.78% (n = 72) had two or more associated morbidities. The main non-oncological diagnoses observed in the total study population were non-inflammatory disorders of female genital tract, 70.10% (n = 300), and urinary tract diseases, 18.22% (n = 78). The chances of breast diseases and non-inflammatory disorders of female genital tract during the reproductive period correspond to 3.61 (CI 1.00-16.29) and 2.56 times (CI 1.00-4.16) higher, respectively than the chance of disease in the non-reproductive period (p < 0.001). Conclusion: The main non-oncological diagnoses in gynecology are non-inflammatory disorders of female genital tract (N80-99) and diseases of urinary tract (N30-N39). Urinary tract diseases (N30-N39), general examination, contraception and procreation (Z00-31) were the diagnoses that remained between the primary and secondary sectors