The Oxford Knee Score (OKS) is a popular single summary questionnaire developed to measure the effect of knee replacement surgery from the patients' perspective. There has been a recent interest in the use of the OKS in populations of patients and in roles it has not been originally developed for. To date, no evidence has been provided about the measurement properties of the OKS when it is used outside the context or purpose for which it was originally designed. The general aim of this thesis is to investigate the measurement properties of the OKS when used in extended roles: a) within the population for which the OKS was originally intended and developed for (knee replacement) and, b) when applied on a different population, viz. patients undergoing non-operative treatment for knee osteoarthritis (OA). Four existing large-scale databases of patients undergoing knee replacement surgery and a database obtained from a prospective study on patients undergoing non-surgical management for knee OA were analyzed. The results demonstrate that: 1) it is possible to extract separate information on pain and functional disability from the OKS in a meaningful way (in the form of subscales). 2) For the first time, anchor-based Minimal Important Change (MIC) of 9 points and Minimal Important Difference (MID) of 5 points were established for joint replacement surgery. 3) The OKS demonstrated satisfactory evidence reliability, validity, responsiveness, and interpretability, when used in patients who are undergoing non-operative management for their knee OA. 4) Further evidence of validity was demonstrated by fitting the OKS to the Rasch model. 5) Lastly, it was demonstrated that thresholds can be applied on the OKS to distinguish between patients who consider their knee problem to be severe enough to warrant joint replacement surgery versus patients who do not. This supports the potential use of the OKS in decision making aids for secondary care referral. Overall the thesis provides critical evidence, not previously existing, to support the continued use, and extended use, of the OKS in orthopaedic medicine.

Medication-related problems (MRPs) are a common issue that lead to suboptimal healthcare outcomes and increased healthcare cost. Overall, older adults have a high risk of experiencing MRPs due to large medication consumption and recession of biological functions. One approach to reduce such a risk is for elderly patients to use comprehensive medication reviews (CMRs), the fundamental service of Medication Therapy Management (MTM). The Centers of Medicare and Medicaid (CMS) has been promoting CMRs among Medicare Part D beneficiaries since 2009, such as offering of an annual free CMR to eligible MTM beneficiaries and making “CMR completion rate” a quality rating (Star) measurement for Part D plans. However, statistics from the report of CMS 2017 Star rating measures showed that the CMR completion rate among MTM eligible was still low. Even though Medicare Part D beneficiaries ultimately make the decision, there are insufficient U.S. studies examining patient perceived factors affecting their use of CMRs. Thus, there is critical need to better understand decision making for using CMRs from a consumer perspective. This dissertation project aimed to explore Medicare Part D beneficiaries’ perceptions on using a CMR, using a conceptual framework adapted from consumer decision making, which consisted of internal need, external influence, perceived risks of using CMRs, and alternative comparison. The dissertation project also aimed to describe how CMR recipients and non-recipients were different and to identify main factors associated with Medicare Part D beneficiaries’ decision making for using CMRs. To achieve these objectives, this study used an exploratory sequential mixed-method approach in a cross-sectional setting. Semi-structured personal interviews were conducted as the qualitative phase followed by self-administered mailed survey as the quantitative phase. Both interview questions and survey items were developed based on the conceptual framework, though findings from qualitative phase informed the survey item generation as well. Survey items and administration were further refined using a panel of expert review and pilot study. A convenient sample consisted of older adults recruited from one pharmacy in Iowa and a senior registry maintained by University of Iowa was used for the qualitative phase (n = 13). The quantitative study sample were randomly selected from each sampling frame: 1) elderly residents of the States of Florida (n = 320), Washington (n = 320), Wisconsin (n = 320), and Pennsylvania (n = 320) covered in a commercial mailing list; and 2) older adults included in the same senior registry used for the qualitative phase (n = 460). The study inclusion criteria were: 1) must be at least 65 years old in 2016, 2) must be taking at least one prescription currently, and 3) must be a Medicare Part D beneficiary. A thematic analysis was conducted for qualitative data, using MaxQDA version 12. Descriptive analysis and multiple logistic regression modeling were used to analyze data of the quantitative phase, using SAS version 9.4. A total of 13 study participants were included in the qualitative analysis, of which 5 were CMR recipients. The thematic analysis yielded five themes, which supported the use of the conceptual framework (i.e. internal need, external influences, perceived risks of using CMRs, and alternative comparison) to understand Medicare Part D beneficiaries’ decision making for using CMRs. Plus, consumers who received a CMR expressed a positive attitude towards them. Safety worriers or knowledge seekers appeared more likely to use CMRs while physician believers or privacy worriers are more likely to not use CMRs. Meanwhile, awareness of CMRs remains low after being available for 7 years, possibly due to an infrequent marketing activity. An overall usable response rate of 26.8% and an overall completion rate of 89.4% were obtained in the mailed survey phase. Of the study sample, 381 respondents who were Medicare Part D beneficiaries, were using at least one prescription, and returned a complete survey were included for analysis. There were 27.56% respondents (n = 105) reported that they had a CMR in 2016 or before, which was consistent with the low CMR completion rate nationwide. Meanwhile, about two thirds of respondents never heard of CMRs, supporting findings from the qualitative phase. CMR recipients and non-recipients had several characteristics differences in the domain of internal need, external influences, and perceived risks of using CMRs. Compared to CMR non-recipients, CMR recipients took slightly more prescription medications (p = 0.0299), were self-reported less healthy (p = 0.0009), had better provider communication in previous pharmacy encounters (p < 0.0001), had higher overall satisfaction in previous pharmacy encounters (p = 0.0053), perceived more seriousness of MRPs (p = 0.0016), perceived more susceptibility of MRPs (p < 0.0001), expected more positive outcome from suing CMRs (p < 0.0001), were more likely influence by a physician’s opinion (p = 0.0184) or a pharmacist’s opinion (p < 0.0001) when considering the use of CMRs, were more likely received a physician recommendation (p < 0.0001) or a pharmacist recommendation (p < 0.0001), had less concern of psychological risk (p = 0.0170), functional risk (p < 0.0001), and social risk (p = 0.0016). The regression modeling further determined that a pharmacist or a physician recommendation, pharmacist’s communication in previous pharmacy encounters, perceived susceptibility of MRPs, and positive outcome expectancy were positively associated with Medicare Part D beneficiaries’ decision making for using CMRs at a significant level of .05, when holding other variables fixed. Meanwhile, perceived functional risk, access to general counseling in previous experiences, and family/friends influence were negatively associated with Medicare Part D beneficiaries’ decision making for suing CMRs at a significant level of .05, when holding other variables fixed. This study is the first to adapt consumer behavior frameworks to explore factors affecting Medicare Part D beneficiaries’ decision making for using CMRs. Unfortunately, it was found that CMR awareness among older population was still low after years’ of promotion efforts among Medicare Part D beneficiaries. Findings of this dissertation suggested that policy makers should not entirely focus on promoting CMRs through Part D plan sponsors, but seek for collaborations from healthcare professionals, particularly community pharmacists and physicians. Meanwhile, addressing key components and benefits of CMRs in an understandable way to general older population could help them establish a link between benefit expectation and their demand. Furthermore, using short surveys or phone interviews to obtain self-perceived internal need among older population could be used by Part D plans or other stakeholders to target potential CMR users more effectively.

Tuberculosis (TB) is a major public health problem in many low- and middle-income countries, including Indonesia. To accelerate TB case detection, and to improve the quality of diagnosis and treatment provided by all providers, the Public-Private Mix for implementing Directly Observed Treatment Short-course (PPM DOTS) was introduced in 2000. However, previous studies on PPM DOTS have focused on private practitioners and there has been a scarcity of research on PPM DOTS in the hospital setting. This dissertation aims to capture the potential of the PPM DOTS strategy, and identify the barriers to its implementation in hospitals in Indonesia. This dissertation is based on four separate but interrelated studies: 1. A costeffectiveness analysis, comparing incremental cost per additional number of TB cases successfully treated under three strategies of PPM DOTS in four provinces. 2. An evaluation of the access to TB services by a cross-sectional study among 62 hospitals, by estimating the proportion of TB cases receiving standardised diagnosis and treatment according to the DOTS strategy. The data were analysed using poststratification analysis. 3. The quality aspect was explored in a multiple-case study, including eight selected hospitals. The data were analysed using cross-case analysis. 4. The process of partnership was explored through a qualitative study. In-depth interviews were conducted with 33 informants, who were actors involved in PPM DOTS in hospitals in Yogyakarta province. Content analysis was applied to the qualitative data. PPM DOTS in hospitals was shown to be a cost-effective intervention in this particular context. However, the quality of the implementation was commonly suboptimal. In addition, a substantial number of TB cases did not get standardised diagnosis and treatment as per the DOTS strategy. The process of creating partnership among hospitals and National TB Programme was shown to be complex and dynamic. Process factors, such as commitment to collaboration and interaction and trust among the actors, were shown to be important. The rapid scaling-up of PPM DOTS in hospitals at the national level in Indonesia should be revisited. Indeed, considering the importance of hospitals in TB control, the implementation should be continued and expanded. However, more attention needs to be given to process, context and governance.

Resumo não disponível / Telemedicina

Resumo não disponível / Telemedicina

Resumo não disponível / Telemedicina

Objetivo. Identificar aspectos éticos das pesquisas qualitativas em saúde, de acordo com os pesquisadores que adotam estas abordagens. Identificar os aspectos da Resolução 196/96 CNS que são aplicáveis, e os que não são aplicáveis às pesquisas qualitativas em saúde. Métodos. A partir da busca no Medline, pelas palavras ética, pesquisa, qualitativa, no período 1993 a 2005, foram localizadas 245 referências. Estas foram classificadas em oito grandes temas das quais foram analisadas, neste trabalho, as que discutiam ética em pesquisa qualitativa, método, epistemologia e trabalho dos comitês de ética. Ao todo, foram analisados 42 artigos, tomando a hermenêutica como referência. A partir da imersão no material, foram identificados temas e categorias. Resultados. Nas pesquisas qualitativas em saúde, os aspectos éticos e aspectos metodológicos freqüentemente estão relacionados. Assim, o compromisso com a justiça social é um dos critérios de qualidade da pesquisa qualitativa e um aspecto ético importante. O consentimento é fundamental, porém deve respeitar as características da relação estabelecida entre pesquisador e pesquisado, a cultura do grupo pesquisado e as características dos indivíduos, como anos de escolaridade. É necessário identificar e respeitar a decisão do pesquisado: seja pelo desejo do anonimato ou, ao contrário a co-autoria do trabalho. É usual enviar aos pesquisados o material produzido e a análise antes de sua publicação, para conferir se estes se sentem representados e se a divulgação destes resultados poderão causar algum dano a indivíduos ou a comunidade pesquisada. A concepção de pesquisa apresentada pelos pesquisadores qualitativos não é a mesma que a adotada pela Resolução 196/96 do Conselho Nacional de Saúde. Para os pesquisadores qualitativos, a pesquisa tem desenho emergente, as definições da pesquisa podem ser tomadas conjuntamente com os pesquisados, a relação que se estabelece entre pesquisador e pesquisado é próxima e de confiança e a pesquisa é realizada no ambiente onde as coisas usualmente acontecem. A definição de pesquisa adotada pela Resolução 196/96 implica em teste de hipótese e as decisões são tomadas previamente pelo pesquisador, que pode apresentar todos os procedimentos previamente. Usualmente é realizada em instituições de saúde ou clínicas de pesquisa que devem ter infra-estrutura adequada, existe a previsão de teste em animais e uso de placebo, bem como suspensão de medicamentos. Conclusões. A Resolução adota uma definição de pesquisa diferente da adotada pelos pesquisadores qualitativos. Além disso, estes pesquisadores têm concepções próprias sobre ética em pesquisa que não estão contempladas na Resolução 196/96, tais como: como manejar a subjetividade e a objetividade; como superar a visão do pesquisador; como se relacionar com o pesquisado, durante e após o término do estudo; como lidar quando o pesquisador toma ciência de atos ilícitos praticados pelos pesquisados; a importância de avaliar o funcionamento de instituições, apresentando à sociedade e possibilitando julgamento público. Assim, sugere-se a elaboração de diretrizes específicas para análise dos aspectos éticos das pesquisas qualitativas em saúde. / Objective. To identify ethical aspects found in qualitative health research, as per researchers that adopt this kind of research approach. To identify aspects pertaining to Resolução 196/96 CNS (Resolution 196/96 CNS) – including those that are applicable to qualitative health research, and those that are not. Methods. Starting from a Medline search, for key words i.e. ethics, research and qualitative, comprehending the period between 1993 and 2005, 245 references were located. These were classified under eight large thematic areas, and those which discussed ethics in qualitative research, methods, epistemology and work within ethical committees were selected to be analyzed in this doctorate dissertation. Altogether, 42 were the papers analyzed as per the Hermeneutic framework. From immersion in the material, themes and categories were identified. Results. In qualitative health research, both ethical and methodological aspects are frequently related. Therefore, commitment with social justice is one of the criteria for assessing the quality of qualitative research, besides being an important ethical feature. Consent is fundamental, but it must respect characteristics of the relationship established between researcher and the researched individual, as well as the latter’s community culture, and individual characteristics – such as years of study. It is necessary to identify and respect the researched person’s decision: for anonymity or, on the contrary, for co-authorship in the paper. It is common to see that the researched individual receives a copy of the material produced, as well as the analysis prior to their publication, so as a means of checking if they feel they are represented or if the results could cause any damage to the individuals or community that has been researched. The concept of research presented by qualitative researchers is not the same adopted by Resolução 196/96 published by the Conselho Nacional de Saúde (National Health Council). According to qualitative researchers, research is designed as per emerging needs, definitions are taken in collaboration with the group being researched, there is a close and trusting relationship established between researcher and researched individual or group, and the research is carried out in the environment in which things usually occur. The definition of research adopted by Resolução 196/96 implies in testing hypotheses, and decisions are previously taken by the researcher – entitled to present all procedures beforehand. It is usually carried out in health institutions that must have the adequate infra-structure; tests are predicted to be carried out on animals, and there is the use of placebo, as well as drugs suspension. Conclusions. The Resolution (Resolução 196/96) adopts a different definition of qualitative research than that adopted by qualitative researchers. Besides, these researchers have their own ideas on the issue of ethics in research – not taken into account by Resolução 196/96, such as: how to deal with subjectivity and objectivity; how to overcome the researcher’s own view; how to maintain a relationship with the researched group during the study, and after it is finished; how to deal with the knowledge (by the researcher) of illicit action taken by the researched individual; the importance of assessing how institutions work, presenting it to society so as to allow for public evaluation. It is therefore suggested that specific guidelines be designed for the analyses of specific ethical aspect within qualitative health research.

Objetivo. Identificar aspectos éticos das pesquisas qualitativas em saúde, de acordo com os pesquisadores que adotam estas abordagens. Identificar os aspectos da Resolução 196/96 CNS que são aplicáveis, e os que não são aplicáveis às pesquisas qualitativas em saúde. Métodos. A partir da busca no Medline, pelas palavras ética, pesquisa, qualitativa, no período 1993 a 2005, foram localizadas 245 referências. Estas foram classificadas em oito grandes temas das quais foram analisadas, neste trabalho, as que discutiam ética em pesquisa qualitativa, método, epistemologia e trabalho dos comitês de ética. Ao todo, foram analisados 42 artigos, tomando a hermenêutica como referência. A partir da imersão no material, foram identificados temas e categorias. Resultados. Nas pesquisas qualitativas em saúde, os aspectos éticos e aspectos metodológicos freqüentemente estão relacionados. Assim, o compromisso com a justiça social é um dos critérios de qualidade da pesquisa qualitativa e um aspecto ético importante. O consentimento é fundamental, porém deve respeitar as características da relação estabelecida entre pesquisador e pesquisado, a cultura do grupo pesquisado e as características dos indivíduos, como anos de escolaridade. É necessário identificar e respeitar a decisão do pesquisado: seja pelo desejo do anonimato ou, ao contrário a co-autoria do trabalho. É usual enviar aos pesquisados o material produzido e a análise antes de sua publicação, para conferir se estes se sentem representados e se a divulgação destes resultados poderão causar algum dano a indivíduos ou a comunidade pesquisada. A concepção de pesquisa apresentada pelos pesquisadores qualitativos não é a mesma que a adotada pela Resolução 196/96 do Conselho Nacional de Saúde. Para os pesquisadores qualitativos, a pesquisa tem desenho emergente, as definições da pesquisa podem ser tomadas conjuntamente com os pesquisados, a relação que se estabelece entre pesquisador e pesquisado é próxima e de confiança e a pesquisa é realizada no ambiente onde as coisas usualmente acontecem. A definição de pesquisa adotada pela Resolução 196/96 implica em teste de hipótese e as decisões são tomadas previamente pelo pesquisador, que pode apresentar todos os procedimentos previamente. Usualmente é realizada em instituições de saúde ou clínicas de pesquisa que devem ter infra-estrutura adequada, existe a previsão de teste em animais e uso de placebo, bem como suspensão de medicamentos. Conclusões. A Resolução adota uma definição de pesquisa diferente da adotada pelos pesquisadores qualitativos. Além disso, estes pesquisadores têm concepções próprias sobre ética em pesquisa que não estão contempladas na Resolução 196/96, tais como: como manejar a subjetividade e a objetividade; como superar a visão do pesquisador; como se relacionar com o pesquisado, durante e após o término do estudo; como lidar quando o pesquisador toma ciência de atos ilícitos praticados pelos pesquisados; a importância de avaliar o funcionamento de instituições, apresentando à sociedade e possibilitando julgamento público. Assim, sugere-se a elaboração de diretrizes específicas para análise dos aspectos éticos das pesquisas qualitativas em saúde. / Objective. To identify ethical aspects found in qualitative health research, as per researchers that adopt this kind of research approach. To identify aspects pertaining to Resolução 196/96 CNS (Resolution 196/96 CNS) – including those that are applicable to qualitative health research, and those that are not. Methods. Starting from a Medline search, for key words i.e. ethics, research and qualitative, comprehending the period between 1993 and 2005, 245 references were located. These were classified under eight large thematic areas, and those which discussed ethics in qualitative research, methods, epistemology and work within ethical committees were selected to be analyzed in this doctorate dissertation. Altogether, 42 were the papers analyzed as per the Hermeneutic framework. From immersion in the material, themes and categories were identified. Results. In qualitative health research, both ethical and methodological aspects are frequently related. Therefore, commitment with social justice is one of the criteria for assessing the quality of qualitative research, besides being an important ethical feature. Consent is fundamental, but it must respect characteristics of the relationship established between researcher and the researched individual, as well as the latter’s community culture, and individual characteristics – such as years of study. It is necessary to identify and respect the researched person’s decision: for anonymity or, on the contrary, for co-authorship in the paper. It is common to see that the researched individual receives a copy of the material produced, as well as the analysis prior to their publication, so as a means of checking if they feel they are represented or if the results could cause any damage to the individuals or community that has been researched. The concept of research presented by qualitative researchers is not the same adopted by Resolução 196/96 published by the Conselho Nacional de Saúde (National Health Council). According to qualitative researchers, research is designed as per emerging needs, definitions are taken in collaboration with the group being researched, there is a close and trusting relationship established between researcher and researched individual or group, and the research is carried out in the environment in which things usually occur. The definition of research adopted by Resolução 196/96 implies in testing hypotheses, and decisions are previously taken by the researcher – entitled to present all procedures beforehand. It is usually carried out in health institutions that must have the adequate infra-structure; tests are predicted to be carried out on animals, and there is the use of placebo, as well as drugs suspension. Conclusions. The Resolution (Resolução 196/96) adopts a different definition of qualitative research than that adopted by qualitative researchers. Besides, these researchers have their own ideas on the issue of ethics in research – not taken into account by Resolução 196/96, such as: how to deal with subjectivity and objectivity; how to overcome the researcher’s own view; how to maintain a relationship with the researched group during the study, and after it is finished; how to deal with the knowledge (by the researcher) of illicit action taken by the researched individual; the importance of assessing how institutions work, presenting it to society so as to allow for public evaluation. It is therefore suggested that specific guidelines be designed for the analyses of specific ethical aspect within qualitative health research.

Introdução: Atenção primária à saúde (APS), conforme definida por Starfield, são serviços de saúde que apresentam como principais atributos o acesso de primeiro contato, a longitudinalidade, a integralidade e a coordenação do cuidado, e estão relacionados em diversas pesquisas com efetividade e equidade dos serviços de saúde, assim como redução de hospitalizações por condições sensíveis à APS (CSAPS). Objetivo: Avaliar, através de Revisão sistemática (RS), o impacto dos atributos da APS nas hospitalizações preveníveis e verificar a associação entre internações CSAPS e a qualidade da APS prestada nos serviços públicos de saúde de Porto Alegre / Brasil. Metodologia: Revisão sistemática realizada nas principais bases de dados eletrônicos e estudo de coorte construído através de relacionamento probabilístico entre bases de dados, no período de 2006 a 2011, com adultos maiores de 18 anos de idade, usuários dos serviços públicos de APS. Para a avaliação da APS foi utilizado o “Instrumento de Avaliação da APS” (PCATool – Brasil). A análise dos dados do estudo de coorte foi feita através de regressão de Cox. Resultados: Foram incluídos 36 artigos na RS. A maioria dos resultados mostrou impacto positivo dos atributos essenciais na redução de hospitalizações, principalmente acesso e longitudinalidade. Nenhum estudo avaliando a orientação dos serviços à APS foi encontrado. No estudo longitudinal, dos 1200 indivíduos acompanhados, 84 foram hospitalizados por CSAPS, representando 21,6% das internações totais. As causas principais de internação foram cardiovasculares (40,5%) e respiratórias (16,2%). O escore médio do PCATool foi de 5,3, inferior ao definido como alta qualidade (6,6). Na análise ajustada, permaneceram no modelo as seguintes variáveis: idade (HR: 1,13; p=0,001), escolaridade (HR: 0,66; p=0,02), cor da pele 12 não branca (HR: 1,77; p=0,01) e sedentarismo (HR: 1,65; p=0,04). O escore geral da APS não teve significância estatística (5,42 vs. 5,31, p=0,1). Conclusões: Embora tenham sido verificados resultados positivos na redução das hospitalizações evitáveis entre os trabalhos incluídos na RS, estudos que avaliem a orientação à APS nos serviços de saúde devem ser realizados. Serviços de saúde com qualidade subótima não impactaram nas hospitalizações evitáveis, enquanto que características sociodemográficas, principalmente cor da pele e escolaridade, tiveram papel relevante na manutenção das iniquidades em saúde e no processo de adoecimento individual. Para alcançar o impacto destes atributos da APS sobre as internações por CSAPS, identificados principalmente na literatura internacional, é imprescindível que o governo brasileiro priorize política e financeiramente a qualificação dos serviços de APS. / Introduction: Primary health care, defined for its attributes access, longitudinality, integrality and coordination, has been related with effectiveness and equity of health care services as with reductions on hospitalizations for ambulatory care sensitive conditions. Objectives: Estimate by systematic review the impact of primary care attributes on hospitalizations for ambulatory care sensitive conditions and establish the relation between hospitalizations for this conditions and the quality of public primary care health services in Porto Alegre/Brazil. Methods: Systematic review from the main electronic databases and a cohort study by probabilistic record linkage between databases, done from July 2006 to December 2011, population > 18 years that attend public health services. The Primary Care Assessment Tool (PCATool - Brazil) was utilized for evaluation of primary care services. Cox regression was utilized for statistical analysis. Results: Thirty-six articles were included in the systematic review. Studies evaluating orientation of primary care were not found. Most of the studies have shown a favorable impact of the essential attributes of primary care on hospitalizations reduction, especially access and longitudinality. In the cohort study, from de 1200 subjects followed in this period, 84 were hospitalized for primary care sensitive conditions, consisting of 21,6% of the total hospitalizations. The main cause of hospital admissions were cardiovascular (40.5%) and respiratory (16.2%) diseases. The PCATool average score was 5.3, less than high quality definition score (6.6). Crude analysis showed significant association with years of study (HR: 0.87; p<0.001), age > 60 years old (HR:3.66; p<0.001), skin color other than white (HR:1.76, p=0.001), lower economic status 14 (HR:1,95; p=0,04), chronic disease (HR:1,69; p=0,02), obesity (HR:1.59; p=0.04) and inactivity (HR: 2.01; p=0.003). Remained on the final multivariable model age > 60 years old (HR:1.13; p=0.001), years of study ( HR:0.66; p=0.02), skin color other than white (HR: 1.77; p=0.01) and physical inactivity (HR: 1.65; p=0.04). The primary care general score was not statistically significant (5.42 vs. 5.31, p=0.1). Conclusion: Although favorable results have been found on hospitalizations reduction, studies that analyze the primary care orientation of the health service still need to be done. Health care services with suboptimal quality didn´t impact on avoidable hospitalizations, while social and demographic characteristics, specially skin color and years of study, had relevant role in maintaining inequities in health process and individual sickness. / Telemedicina

Introdução: Atenção primária à saúde (APS), conforme definida por Starfield, são serviços de saúde que apresentam como principais atributos o acesso de primeiro contato, a longitudinalidade, a integralidade e a coordenação do cuidado, e estão relacionados em diversas pesquisas com efetividade e equidade dos serviços de saúde, assim como redução de hospitalizações por condições sensíveis à APS (CSAPS). Objetivo: Avaliar, através de Revisão sistemática (RS), o impacto dos atributos da APS nas hospitalizações preveníveis e verificar a associação entre internações CSAPS e a qualidade da APS prestada nos serviços públicos de saúde de Porto Alegre / Brasil. Metodologia: Revisão sistemática realizada nas principais bases de dados eletrônicos e estudo de coorte construído através de relacionamento probabilístico entre bases de dados, no período de 2006 a 2011, com adultos maiores de 18 anos de idade, usuários dos serviços públicos de APS. Para a avaliação da APS foi utilizado o “Instrumento de Avaliação da APS” (PCATool – Brasil). A análise dos dados do estudo de coorte foi feita através de regressão de Cox. Resultados: Foram incluídos 36 artigos na RS. A maioria dos resultados mostrou impacto positivo dos atributos essenciais na redução de hospitalizações, principalmente acesso e longitudinalidade. Nenhum estudo avaliando a orientação dos serviços à APS foi encontrado. No estudo longitudinal, dos 1200 indivíduos acompanhados, 84 foram hospitalizados por CSAPS, representando 21,6% das internações totais. As causas principais de internação foram cardiovasculares (40,5%) e respiratórias (16,2%). O escore médio do PCATool foi de 5,3, inferior ao definido como alta qualidade (6,6). Na análise ajustada, permaneceram no modelo as seguintes variáveis: idade (HR: 1,13; p=0,001), escolaridade (HR: 0,66; p=0,02), cor da pele 12 não branca (HR: 1,77; p=0,01) e sedentarismo (HR: 1,65; p=0,04). O escore geral da APS não teve significância estatística (5,42 vs. 5,31, p=0,1). Conclusões: Embora tenham sido verificados resultados positivos na redução das hospitalizações evitáveis entre os trabalhos incluídos na RS, estudos que avaliem a orientação à APS nos serviços de saúde devem ser realizados. Serviços de saúde com qualidade subótima não impactaram nas hospitalizações evitáveis, enquanto que características sociodemográficas, principalmente cor da pele e escolaridade, tiveram papel relevante na manutenção das iniquidades em saúde e no processo de adoecimento individual. Para alcançar o impacto destes atributos da APS sobre as internações por CSAPS, identificados principalmente na literatura internacional, é imprescindível que o governo brasileiro priorize política e financeiramente a qualificação dos serviços de APS. / Introduction: Primary health care, defined for its attributes access, longitudinality, integrality and coordination, has been related with effectiveness and equity of health care services as with reductions on hospitalizations for ambulatory care sensitive conditions. Objectives: Estimate by systematic review the impact of primary care attributes on hospitalizations for ambulatory care sensitive conditions and establish the relation between hospitalizations for this conditions and the quality of public primary care health services in Porto Alegre/Brazil. Methods: Systematic review from the main electronic databases and a cohort study by probabilistic record linkage between databases, done from July 2006 to December 2011, population > 18 years that attend public health services. The Primary Care Assessment Tool (PCATool - Brazil) was utilized for evaluation of primary care services. Cox regression was utilized for statistical analysis. Results: Thirty-six articles were included in the systematic review. Studies evaluating orientation of primary care were not found. Most of the studies have shown a favorable impact of the essential attributes of primary care on hospitalizations reduction, especially access and longitudinality. In the cohort study, from de 1200 subjects followed in this period, 84 were hospitalized for primary care sensitive conditions, consisting of 21,6% of the total hospitalizations. The main cause of hospital admissions were cardiovascular (40.5%) and respiratory (16.2%) diseases. The PCATool average score was 5.3, less than high quality definition score (6.6). Crude analysis showed significant association with years of study (HR: 0.87; p<0.001), age > 60 years old (HR:3.66; p<0.001), skin color other than white (HR:1.76, p=0.001), lower economic status 14 (HR:1,95; p=0,04), chronic disease (HR:1,69; p=0,02), obesity (HR:1.59; p=0.04) and inactivity (HR: 2.01; p=0.003). Remained on the final multivariable model age > 60 years old (HR:1.13; p=0.001), years of study ( HR:0.66; p=0.02), skin color other than white (HR: 1.77; p=0.01) and physical inactivity (HR: 1.65; p=0.04). The primary care general score was not statistically significant (5.42 vs. 5.31, p=0.1). Conclusion: Although favorable results have been found on hospitalizations reduction, studies that analyze the primary care orientation of the health service still need to be done. Health care services with suboptimal quality didn´t impact on avoidable hospitalizations, while social and demographic characteristics, specially skin color and years of study, had relevant role in maintaining inequities in health process and individual sickness. / Telemedicina