Submitted by Ana Lúcia Torres (bfmhuap@gmail.com) on 2017-11-13T13:55:12Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) DISSERTAÇAO HENRIQUE ANDRADE.pdf: 904769 bytes, checksum: 5e5f1753233282ece1336c94555dfe79 (MD5) / Approved for entry into archive by Ana Lúcia Torres (bfmhuap@gmail.com) on 2017-11-13T13:55:21Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) DISSERTAÇAO HENRIQUE ANDRADE.pdf: 904769 bytes, checksum: 5e5f1753233282ece1336c94555dfe79 (MD5) / Made available in DSpace on 2017-11-13T13:55:21Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) DISSERTAÇAO HENRIQUE ANDRADE.pdf: 904769 bytes, checksum: 5e5f1753233282ece1336c94555dfe79 (MD5) Previous issue date: 2017 / Universidade Federal Fluminense. Hospital Universitário Antonio Pedro / Universidade Estadual de Campinas / Buscamos realizar nesta pesquisa uma análise sobre a formação discursiva da Medicina de Família e Comunidade (MFC). Tal reflexão foi feita a partir de uma revisão histórica de sua emergência, da análise do discurso de distintos atores que vem influenciando essa formação e de um debate crítico com os horizontes de suas práticas clínicas. Incluem-se nesse debate o modelo biopsicossocial de adoecimento e o uso do conceito de risco, as ferramentas clínicas deles derivadas, a problemática da medicalização social e dos efeitos biopolíticos da prática médica familiar e comunitária. Foram também analisadas diferentes perspectivas sobre a dinâmica histórica do direito à saúde, do progresso e da modernização na formação social brasileira. Pudemos identificar que a formação discursiva da MFC está atravessada a) pela história da prática médica familiar e comunitária especialmente a partir do século XVIII; b) pela constituição dos serviços primários em saúde e da Atenção Primária em Saúde no século XX e c) pelos programas de Medicina Comunitária e pela formação da Saúde Coletiva no Brasil. Além disso, encontra-se atrelada ao campo científico e político da medicina generalista e familiar internacional e a sua afirmação como especialidade médica. A partir dos diferentes discursos analisados, observamos a MFC não como um campo homogêneo, delimitado e com uma histórica única. Podemos também afirmar que a MFC vem constituindo-se como um campo discursivo próprio e com projetos políticos heterogêneos para a organização dos serviços de saúde no país. Em suma, para observarmos os sentidos éticos e políticos da prática médica familiar e comunitária, é necessário ampliar o escopo da análise para além do uso de suas ferramentas clínicas e científicas, inserindo nele compreensões que tragam à tona a história da produção de nós mesmos, das lutas políticas pelo direito à saúde e por formas alternativas de pensar e experienciar a vida / We have aimed to make an analysis about the discursive formation of Family and Community Medicine (MFC). This research was made from a historical revision about its emergence, the discourse analysis of actors that have been influencing this formation and a critical debate about the horizons of its clinical practices. We include in this debate the biopsychosocial model of illness, the use of the concept of risk, the clinical tools derived from this model and this concept, the social medicalization problematic and the biopolitical effects of family and community practice. We have included different perspectives about the historical dynamics of the right to health, the progress and the modernization in Brasil social formation. We could identify that the discursive formation of MFC is crossed by: a) the history of Family and community practice specially from the 18th century; b) the constitution of primary services and Primary Health Care from the 20th century and c) by the programs of Community Medicine and Collective Health in Brasil. Besides, the formation is attached to the scientific and political field of the international generalist and family medicine. From the speeches analyzed, we have observed MFC not as a homogenous and delimited field with a unique history. We can affirm that MFC has been forming itself as a specific discursive field with heterogeneous political projects to the health services organizations in our country. Finally, in order to observe the ethical and political directions of Family and community practice, it is necessary to amplify the scope of the analysis beyond the use of clinical and scientific tools. Therefore, we have to include formulations that bring up the history of the production of ourselves, the political struggles for the right to health and for alternatives forms of thinking and experiencing life

Cervical cancer, a completely curable disease with early detection and management, is an international concern. Early identification allows for treatment of the disease, which prevents or slows progression, ultimately reducing morbidity and mortality. Due to the regressive nature of most cervical lesions, the duration between cervical cytology has been lengthened to prevent over diagnosis and treatment. This was reflected in the 2012 United States Preventative Services Task Force (USPSTF) clinical practice guideline for cervical cancer screening. The purpose of this project was to determine the effectiveness of a quality improvement initiative to increase adherence to the 2012 USPSTF guideline at a volunteer medical clinic for the working uninsured. In this retrospective, time series observational evaluation, data were collected via chart review regarding adherence to the guideline. The intervention consisted of the placement of a visual algorithm educational tool for clinical decision-making for cervical cytology screening in each exam room. Data were collected during three time periods: (1) the 3 months prior to initial education of clinic staff regarding the guideline; (2) the 3months between initial education and introduction of the algorithm; and (3) the 3 months post introduction of the algorithm. A total of 335 charts were reviewed. There was a significant difference in the proportion of appropriate screening among the three groups (Χ2= 6.83 p=.03). There was also a significant difference in appropriate screening rates between the new and established patients’ group, controlling for group (p<.0001). The use of the interventional algorithm is recommended to improve adherence to evidence-based practice guideline related to cervical screening as it decreases harm(s) to the patient by reduction of fear, cost to the patient, and overtreatment of benign regressive lesions.

Intimate partner violence (IPV) is recognized as a serious, growing problem on college campuses. IPV rates among college students exceed estimates reported for the general population. Few studies have examined the impact of IPV among the Hispanic college student (HCS) population or explored how HCSs perceive and experience IPV. Focusing on young adults (ages 18 to 25 years), this mixed methods study was designed to explore the perceptions and experiences of IPV focusing on levels of victimization and perpetration in relation to gender role attitudes and beliefs, exposure to parental IPV, acculturation, and religiosity. A sample of 120 HCSs was recruited from two south Florida universities. A subsample of 20 participants was randomly selected to provide qualitative responses. All participants completed a series of questionnaires including a demographic survey, the FPB, CTS2-CA, SASH, ERS and CTS2. Bivariate correlational techniques and multiple regressions were used to analyze data. Marked discrepancy between participants’ perceived experience of IPV (N = 120) and their CTS2 responses (n = 116, 96.7%). Only 5% of the participants saw themselves as victims or perpetrators of IPV, yet 66% were victims or 67% were perpetrators of verbal aggression; and 31% were victims or 32.5% were perpetrators of sexual coercion based on their CTS2 scores. Qualitative responses elicited from the subsample of 20 students provided some insight regarding this disparity. There was rejection of traditional stratified gender roles. Few participants indicated that they were religious (20.8%, n = 25). Evidence for the theory of intergenerational transmission of violence was noted. Recall of parental IPV was a significant predictor of level of IPV victimization (β = 0.177, SE = 0.85, p = 0.041). Nursing and social service providers must be cognizant that contributing factors to either victimization and/or perpetration of IPV among college students must be addressed first (i.e., perceptions of IPV), both in acute (i.e., emergency department) and community (i.e., college and university) settings for optimum intervention outcome.

The purpose was to examine the effect of a self-care educational intervention on nursing student resilience and thus the potential for compassion fatigue, depersonalization, burnout, depression, and inadequate self-care. A one-group pretest-posttest research design was applied to a convenience sample of 104 nursing students near the end of their last semester in a baccalaureate nursing program. The measurements were demographics, a psychometric resilience scale, program evaluation, and reflection question. The intervention was a standardized, intensive 30 min training program on the high degree of stress and burnout nurses face and the core self-care methods that can promote resilience to these hazards. The educational intervention had a strong positive effect on resilience scores (effect size of r=72%; p < 0.05). Eighty-six percent of the participants believed that the intervention increased their capabilities for self-care, especially in sleep, spending time outside, hydration, nutrition, and physical stretching exercises but not in journaling. Eighty-one percent stated that they would be likely to seek professional help if needed. Although this study must be repeated in other samples before it be implemented with full confidence, the standardized, high intensity, short duration, resilience training session can be recommended to nursing programs just prior to graduation and to hospitals for nurse orientation programs.

Although the problem of patients with dual diagnoses is not new, it has only been in the last few years that their unique and complex problems have begun to be addressed. This recognition coincides with society's concern regarding the magnitude of substance abuse problems in general. Currently, treatment consists of integrating concepts from substance abuse and mental health fields. This integration may improve the therapeutic outcome for these patients. As more experience is gained in this specialty, it is hoped that new treatment concepts will evolve that will more powerfully address the interactive aspect of substance abuse and psychiatric disorders.

Winged scapula is a condition characterized by lateral or medial protrusion of the scapula caused by nerve damage leading to muscular paralysis. The purpose of this systematic review of literature is to evaluate the current research literature related to the effectiveness of therapy options for winged scapula. Eleven peer reviewed English language research articles published from 1998 to present were included for evaluation. Study results revealed positive therapeutic outcomes for physical therapy and scapular bracing. Results also showed positive outcomes for the use of transcutaneous electrical nerve stimulation and acupuncture for the treatment of nerve related conditions similar to winged scapula. Additional research is needed to evaluate the effectiveness of transcutaneous electrical nerve stimulation and acupuncture for winged scapula patients specifically.

Limited research exists about the experiences of nurses’ caring for patients during the COVID-19 pandemic post hoc. To understand nurses’ realities of caring for patients with COVID-19, I aimed to understand the lived experience of nurses caring for patients with COVID-19 in the United States. A qualitative design with a hermeneutic phenomenological methodology was used. Sixteen participants were recruited via purposive sampling, augmented with snowball sampling. Data were collected through unstructured interviews and were analyzed using Braun and Clarke’s Reflexive Thematic Analysis. Nurses’ experiences of caring for patients with COVID-19 in the U.S. were consolidated into four themes: “a living hell”; “rationing patient safety”; “mental aftermath of the war zone”; and “post-pandemic pride”. Nurses provided patient care amidst challenging environments of limited to no resources, with extensive, large-scale critically ill patients, and patient deaths. Due to overwhelming patient care demands, nurses were unable to provide safe patient care to everyone in need, resulting in patient deterioration and death. These experiences caused nurses to endure maladaptive mental effects, such as compassion fatigue and moral suffering, which can threaten the safety of patients. Despite these undesirable results, nurses continued to provide patient care and expressed feelings of pride in the profession of nursing for surviving the COVID-19 pandemic. However, this study demonstrates the persistent impacts on nurses’ abilities to provide safe care after the crisis years. Support for nurses is recommended to preserve patient safety.

O PSF emerge para reordenar o modelo de atenção à saúde. Os objetivos deste trabalho são o de estimar o consumo dos serviços de saúde e identificar a capacidade de oferta de serviços da USF. Foram realizadas entrevistas sobre o consumo de serviços de saúde por amostragem na população adscrita a equipe 01 da USF Jd Pirituba no Município de São Paulo. A procura por serviço de saúde nos 15 dias que precederam a entrevista foi de 22%. O local mais procurado foi o Centro de saúde. O principal motivo de procura foi a consulta clínica (51%). A descrição e análise do consumo efetivo da população adscrita às equipes de PSF pode servir como um importante instrumento para o planejamento das ações da USF / Brazil still has a National Health System unable to meet the needs of the population. Since the year 2001 the city of São Paulo established the Family Health Care Program as a structural strategy for the municipal health system. The hypothesis of this research is that the Family Health Care Program, as the other models of health care, offers services without matching the people utilization of health supplies. To stimate the utilization of health care supplies of a population visited by the Family Program (1360 families) and to identify the care services provided by a Family Health Care team are the objetives of this survey. A community inquiry were carried out among a sample from the population assisted by a family health care team in the Distritct of Pirituba located in the north-west of the city of São Paulo. The supervisor and the general phisicyan were also interviewed in order to estimate the services provided by the health team. The results showed an adult population, low level of literacy and low income. Thirthy-one percent was the population having a supplementary private health insurances. Twenty-two percent of the population seek the care of a professional within 15 days before the interview. The primary care services has the skill to be a portal of entry to the health System. People suffering from hypertension, heart disease and depression use more health services than healthy population. Searching for a physician appointment was 51% of the reasons to go to a health service, showing a poor interdiciplinary teamwork culture. Self-medication was very high for those medicine causing important side-effects. Referring patients to a specialist, having access to high-technology procedures and finding a place at hospitals were the main dificultties found by the family health care team. The health care coverage of the family health care team do not consider the utilization of health services by tha area served by them keeping the old fashion way of planning health services. The services they provide are not enough to meet the needs of the population they visit. The metodology of measuring the needs of the population to be attended is one of the ways to organize and plan a better population-based halth care system.

Abstract Background Cardiovascular disease (CVD) has an enormous impact on the lives and health of New Zealanders. There is substantial epidemiological evidence that supports identifying people at high risk of CVD and treating them with lifestyle and drug-based interventions. If fully implemented, this targeted high risk approach could reduce future CVD events by over 50%. Recent studies have shown that a formal CVD risk assessment to the systematically identify high risk patients is rarely done in routine New Zealand general practice and audits of CVD risk management have shown large evidence-practice gaps. The CVD risk prediction score recommended by New Zealand guidelines for identifying high CVD risk patients was derived from the US Framingham Heart Study using data collected between the 1960s and 1980s. This score has only modest prediction accuracy and there are particular concerns about it’s validity for New Zealand sub-populations such as high risk ethnic groups or people with diabetes. Aims The overall aims of this thesis were to investigate the potential of a computerised decision support system (CDSS) to improve the assessment and management of CVD risk in New Zealand general practice while simultaneously developing a sustainable cohort study that could be used for validating and improving CVD risk prediction scores and related research. Methods An environmental scan of the New Zealand health care setting’s readiness to support a CDSS was conducted .The epidemiological evidence was reviewed to assess the effect of decision support systems on the quality of health care and the types and functionality of systems most likely to be successful. This was followed by a focused systematic review of randomised trials evaluating the impact of CDSS on CVD risk assessment and management practices and patient CVD outcomes in primary care. A web-based CDSS (PREDICT) was collaboratively developed. This rules-based provider-initiated system with audit and feedback and referral functionalities was fully integrated with general practice electronic medical records in a number of primary health organisations (PHOs). The evidence-based content was derived from national CVD and diabetes guidelines. When clinicians used PREDICT at the time of a consultation, treatment recommendations tailored to the patient’s CVD and diabetes risk profile were delivered to support decision-making within seconds. Simultaneously, the patient’s CVD risk profiles were securely stored on a central server. With PHO permission, anonymised patient data were linked via encrypted patient National Health Index numbers to national death and hospitalisation data. Three analytical studies using these data are described in this thesis. The first evaluated changes in GP risk assessment practice following implementation of PREDICT; the second investigated patterns of use of the CDSS by GPs and practice nurses; and the third describes the emerging PREDICT cohort and a preliminary validation of risk prediction scores. Results Given the rapid development of organised primary care since the 1990’s, the high degree of general practice computerisation and the New Zealand policy (health, informatics, privacy) environment, the introduction of a CDSS into the primary care setting was deemed feasible. The evidence for the impact of CDSS in general has been moderately favourable in terms of improving desired practice. Of the randomised trials of CDSS for assessing or managing CVD risk, about two-thirds reported improvements in provider processes and two-fifths reported some improvements in intermediate patient outcomes. No adverse effects were reported. Since 2002, the PREDICT CDSS has been implemented progressively in PHOs within Northland and the three Auckland regional District Health Board catchments, covering a population of 1.5 million. A before-after audit conducted in three large PHOs showed that CVD risk documentation increased four fold after the implementation of PREDICT. To date, the PREDICT dataset includes around 63,000 risk assessments conducted on a cohort of over 48,000 people by over 1000 general practitioners and practice nurses. This cohort has been followed from baseline for a median of 2.12 years. During that time 2655 people died or were hospitalised with a CVD event. Analyses showed that the original Framingham risk score was reasonably well calibrated overall but underestimated risk in high risk ethnic groups. Discrimination was only modest (AUC 0.701). An adjusted Framingham score, recommended by the New Zealand Guideline Group (NZGG) overestimated 5-year event rates by around 4-7%, in effect lowering the threshold for drug therapy to about 10% 5-year predicted CVD risk. The NZGG adjusted score (AUC 0.676) was less discriminating than the Framingham score and over-adjusted for high risk ethnic groups. For the cohort aged 30-74 years, the NZGG-recommended CVD risk management strategy identified almost half of the population as eligible for lifestyle management +/- drug therapy and this group generated 82% of all CVD events. In contrast the original Framingham score classified less than one-third of the cohort as eligible for individualised management and this group generated 71% of the events that occurred during follow-up. Implications This research project has demonstrated that a CDSS tool can be successfully implemented on a large scale in New Zealand general practice. It has assisted practitioners to improve the assessment and management of CVD at the time of patient consultation. Simultaneously, PREDICT has cost-effectively generated one of the largest cohorts of Māori and non-Māori ever assembled in New Zealand. As the cohort grows, new CVD risk prediction scores will be able to be developed for many New Zealand sub-populations. It will also provide clinicians and policy makers with the information needed to determine the trade-offs between the resources required to manage increasing proportions of the populations and the likely impact of management on preventing CVD events.

Abstract Background Cardiovascular disease (CVD) has an enormous impact on the lives and health of New Zealanders. There is substantial epidemiological evidence that supports identifying people at high risk of CVD and treating them with lifestyle and drug-based interventions. If fully implemented, this targeted high risk approach could reduce future CVD events by over 50%. Recent studies have shown that a formal CVD risk assessment to the systematically identify high risk patients is rarely done in routine New Zealand general practice and audits of CVD risk management have shown large evidence-practice gaps. The CVD risk prediction score recommended by New Zealand guidelines for identifying high CVD risk patients was derived from the US Framingham Heart Study using data collected between the 1960s and 1980s. This score has only modest prediction accuracy and there are particular concerns about it’s validity for New Zealand sub-populations such as high risk ethnic groups or people with diabetes. Aims The overall aims of this thesis were to investigate the potential of a computerised decision support system (CDSS) to improve the assessment and management of CVD risk in New Zealand general practice while simultaneously developing a sustainable cohort study that could be used for validating and improving CVD risk prediction scores and related research. Methods An environmental scan of the New Zealand health care setting’s readiness to support a CDSS was conducted .The epidemiological evidence was reviewed to assess the effect of decision support systems on the quality of health care and the types and functionality of systems most likely to be successful. This was followed by a focused systematic review of randomised trials evaluating the impact of CDSS on CVD risk assessment and management practices and patient CVD outcomes in primary care. A web-based CDSS (PREDICT) was collaboratively developed. This rules-based provider-initiated system with audit and feedback and referral functionalities was fully integrated with general practice electronic medical records in a number of primary health organisations (PHOs). The evidence-based content was derived from national CVD and diabetes guidelines. When clinicians used PREDICT at the time of a consultation, treatment recommendations tailored to the patient’s CVD and diabetes risk profile were delivered to support decision-making within seconds. Simultaneously, the patient’s CVD risk profiles were securely stored on a central server. With PHO permission, anonymised patient data were linked via encrypted patient National Health Index numbers to national death and hospitalisation data. Three analytical studies using these data are described in this thesis. The first evaluated changes in GP risk assessment practice following implementation of PREDICT; the second investigated patterns of use of the CDSS by GPs and practice nurses; and the third describes the emerging PREDICT cohort and a preliminary validation of risk prediction scores. Results Given the rapid development of organised primary care since the 1990’s, the high degree of general practice computerisation and the New Zealand policy (health, informatics, privacy) environment, the introduction of a CDSS into the primary care setting was deemed feasible. The evidence for the impact of CDSS in general has been moderately favourable in terms of improving desired practice. Of the randomised trials of CDSS for assessing or managing CVD risk, about two-thirds reported improvements in provider processes and two-fifths reported some improvements in intermediate patient outcomes. No adverse effects were reported. Since 2002, the PREDICT CDSS has been implemented progressively in PHOs within Northland and the three Auckland regional District Health Board catchments, covering a population of 1.5 million. A before-after audit conducted in three large PHOs showed that CVD risk documentation increased four fold after the implementation of PREDICT. To date, the PREDICT dataset includes around 63,000 risk assessments conducted on a cohort of over 48,000 people by over 1000 general practitioners and practice nurses. This cohort has been followed from baseline for a median of 2.12 years. During that time 2655 people died or were hospitalised with a CVD event. Analyses showed that the original Framingham risk score was reasonably well calibrated overall but underestimated risk in high risk ethnic groups. Discrimination was only modest (AUC 0.701). An adjusted Framingham score, recommended by the New Zealand Guideline Group (NZGG) overestimated 5-year event rates by around 4-7%, in effect lowering the threshold for drug therapy to about 10% 5-year predicted CVD risk. The NZGG adjusted score (AUC 0.676) was less discriminating than the Framingham score and over-adjusted for high risk ethnic groups. For the cohort aged 30-74 years, the NZGG-recommended CVD risk management strategy identified almost half of the population as eligible for lifestyle management +/- drug therapy and this group generated 82% of all CVD events. In contrast the original Framingham score classified less than one-third of the cohort as eligible for individualised management and this group generated 71% of the events that occurred during follow-up. Implications This research project has demonstrated that a CDSS tool can be successfully implemented on a large scale in New Zealand general practice. It has assisted practitioners to improve the assessment and management of CVD at the time of patient consultation. Simultaneously, PREDICT has cost-effectively generated one of the largest cohorts of Māori and non-Māori ever assembled in New Zealand. As the cohort grows, new CVD risk prediction scores will be able to be developed for many New Zealand sub-populations. It will also provide clinicians and policy makers with the information needed to determine the trade-offs between the resources required to manage increasing proportions of the populations and the likely impact of management on preventing CVD events.