Este estudo buscou avaliar, em um município de médio porte, a adequação da estrutura e dos processos da atenção primária à saúde às orientações disponíveis. Metodologia: Usando um recorte transversal, avaliamos a estrutura, com base nas orientações do Ministério da Saúde, através de entrevistas com as 24 coordenadoras de UBS, e os processos, com base no grau de orientação para APS pelo PCATool-Brasil, através de entrevistas com 98 médicos e enfermeiros. Resultados: Encontramos adequação a uma série de características estruturais e inadequação a outras como, por exemplo, alto número de habitantes por equipe, baixa oferta de consultas, baixa formação profissional para a APS e falta de avaliação sistemática das ações. Da mesma forma, um processo satisfatório em alguns atributos da APS e insatisfatório em acesso de primeiro contato (escore: 3,6) e longitudinalidade (escore: 6,0). Conclusão: A adequação do sistema de saúde de Chapecó implica em ampliar 56 mil consultas médicas/ano, 2 novas UBS, estimular a formação profissional para APS e estimular a avaliação sistemática das ações. / This study sought evaluate, in the scenario of a mid-size city, the adequacy of the structure and processes of primary health care (PHC) to the directions avaliable. Methodology: Using a cross-sectional study, we evaluate the structure on the basis of the directions of the Health Ministry, through interviews with 24 the coordinators of the Health Basic Units (HBU), and process on the basis of the level measurement for PHC measured by Primary Care Assessment Tool (PCATool-Brazil), through interviews with 98 professional doctors and nurses. Results: We observe accordance with a whole series of structural characteristics directions by the Health Ministry and inadequate to others as, for example, on the high number of inhabitants by team, the low offer of medical consultations, vocational training low for PHC and lack of systematic evaluation of actions. At the same time, it demonstrates a satisfactory process in some attributes of the PHC and unsatisfactory in relation to the first-contact access (score: 3,6) and longitudinality (score: 6,0). Conclusion: The adequacy in Chapecó of the health system, implies enlarge 56 thousand medical consultations/year, 2 new HBU, stimulate vocational training for PHC and encourage the systematic evaluation of actions.

Este estudo buscou avaliar, em um município de médio porte, a adequação da estrutura e dos processos da atenção primária à saúde às orientações disponíveis. Metodologia: Usando um recorte transversal, avaliamos a estrutura, com base nas orientações do Ministério da Saúde, através de entrevistas com as 24 coordenadoras de UBS, e os processos, com base no grau de orientação para APS pelo PCATool-Brasil, através de entrevistas com 98 médicos e enfermeiros. Resultados: Encontramos adequação a uma série de características estruturais e inadequação a outras como, por exemplo, alto número de habitantes por equipe, baixa oferta de consultas, baixa formação profissional para a APS e falta de avaliação sistemática das ações. Da mesma forma, um processo satisfatório em alguns atributos da APS e insatisfatório em acesso de primeiro contato (escore: 3,6) e longitudinalidade (escore: 6,0). Conclusão: A adequação do sistema de saúde de Chapecó implica em ampliar 56 mil consultas médicas/ano, 2 novas UBS, estimular a formação profissional para APS e estimular a avaliação sistemática das ações. / This study sought evaluate, in the scenario of a mid-size city, the adequacy of the structure and processes of primary health care (PHC) to the directions avaliable. Methodology: Using a cross-sectional study, we evaluate the structure on the basis of the directions of the Health Ministry, through interviews with 24 the coordinators of the Health Basic Units (HBU), and process on the basis of the level measurement for PHC measured by Primary Care Assessment Tool (PCATool-Brazil), through interviews with 98 professional doctors and nurses. Results: We observe accordance with a whole series of structural characteristics directions by the Health Ministry and inadequate to others as, for example, on the high number of inhabitants by team, the low offer of medical consultations, vocational training low for PHC and lack of systematic evaluation of actions. At the same time, it demonstrates a satisfactory process in some attributes of the PHC and unsatisfactory in relation to the first-contact access (score: 3,6) and longitudinality (score: 6,0). Conclusion: The adequacy in Chapecó of the health system, implies enlarge 56 thousand medical consultations/year, 2 new HBU, stimulate vocational training for PHC and encourage the systematic evaluation of actions.

Orientador: Djalma de Carvalho Moreira Filho / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-19T07:55:56Z (GMT). No. of bitstreams: 1 Campos_EneidaRached_D.pdf: 1590665 bytes, checksum: 4d824ace74d3c0a91782143ad65c17d0 (MD5) Previous issue date: 2011 / Resumo: Introdução: Ações são encadeadas nas linhas de cuidado para organizar o percurso assistencial do consumidor de saúde. Método: Determinação de interrelações entre os conceitos e as práticas da epidemiologia, da ciência da administração e da lógica de inferência para o estudo de linha de cuidado. Resultados: 1) Criação do Método de Planejamento Epidemiológico de Linha de Cuidado - PELC - para testar e determinar o melhor percurso assistencial e para garantir sua qualidade. O Método PELC forma uma Equipe de Árbitros para definir o Tratamento Padrão (TP) da linha de cuidado e seu Escore PELC-TP; compara cada linha de cuidado (LC) com o Tratamento Padrão e o resultado é representado no Escore PELC-LC; cria base de comparação entre o Grupo Caso- LC e o Grupo Controle-LC; instala estudos epidemiológicos para investigar os fatores clínicos-sociais-organizacionais mais determinantes para os resultados futuros da linha de cuidado. No estudo prospectivo, o Experimento de Gestão oferece as linhas do Grupo Controle-LC. O Sistema do Cuidado Advir monitora a qualidade do cuidado que está por vir. A Saúde Autorreferida pesquisa o grau de autopercepção de saúde do consumidor. 2) Aplicação do Método PELC com delineamento de caso-controle na linha de cuidado das crianças e dos adolescentes infectados pelo HIV. Definição do Tratamento Padrão com PELCTP= 100 e Escore PELC-RES = 51 (sucesso terapêutico). A análise de regressão logística mostrou os seguintes fatores como mais determinantes para PELCRES< 20 e para PELC-LC<75: ter adesão à terapia antirretroviral (OR=0,26; IC95%=0,09-0,69; p=0,007), ter consulta na otorrino (OR=3,9; IC95%=1,27-12,51; p=0,018), ter consulta no serviço social (OR=6,36; IC95%=1,53-44,36; p=0,024) e ter faltado em consultas de rotina (OR=13,01; IC95%=3,42-86,81; p=0,001). Conclusões: O Método PELC abre a discussão de uma nova linha de pesquisa para estudos locais ou multicêntricos de linhas de cuidado / Abstract: Introduction: Actions are linked in lines of care to organize the course of assistance of the healthcare consumer. Method: The determination of correlations between concepts and practices of epidemiology, of administration science and of logic of inference for the study of line of care. Results: 1) The creation of the Method of Epidemiological Planning for the Line of Care - PELC - to test and determine the best assistance course and to ensure its quality. The PELC Method compiles a Team of Referees to define the Standard Treatment (ST) of the line of care and its PELC-ST score; compares each line of care (LC) with the Standard Treatment and the result is represented in the PELC-LC score; it creates a base of comparison between the LC-Case Group and the LC-Control Group; installs epidemiological studies to investigate the most determining clinical-social organizational factors for future results of the line of care. In the prospective study, the Management Experiment offers the lines in the LC-Control Group. The Aftercare System monitors the quality of care that is coming. The Self-referred Healthcare researches the degree of health self-perception of the consumer. 2) Application of the PELC Method with the design of case-control in line of care of children and adolescents infected by HIV. Definition of the Standard Treatment with PELC-ST=100 and PELC-RES=51 score (therapeutic success). The analysis of logistic regression have shown the following factors as the most determinant for PELC-RES<20 and for PELC-LC<75: adhering to the antiretroviral therapy (OR=0.26; IC95%=0.09-0.69; p=0.007), have an appointment at the otolaryngologist (OR=3.9; IC95%=1.27-12.51; p=0.018), have an appointment at social services (OR=6.36; IC95%=1.53-44.36; p=0.024) have missed routine appointments (OR=13.01; IC95%=3.42-86.81; p=0.001). Conclusions: The PELC Method opens the debate of a new line of research for local or multicentre studies in lines of care / Doutorado / Epidemiologia / Doutor em Saude Coletiva

M.A. / Currently there is great emphasis on community development. The researcher was motivated to do the study due to the community centre in Krugersdorp that concentrates on community development. The main goal of this dissertation is to prmulate criteria which community centres can use to function successfully. For the purpose of this study the fallowing objectives were identified: To gather information regarding the functioning qf the community centre in Krugersdorp; to compare this information with the literature on community and social development; from these findings to compile a guideline in connection with the functioning of a community centre based on the development paradigm; and to determine the role of the social worker at the community centre. The role of the social worker at the community centre is determined from information that has been received from interviews as well as a literature study. The community centre works according to R 17 P principles

Objective: Treatment compliance in children with Crohn’s disease is associated with higher levels of symptom remission. We hypothesized that the management, comorbidities, and complications for children with Crohn’s disease would differ based on a diagnosis of noncompliance. Methods: Using the Kids’ Inpatient Database for 2006-2012, we identified young patients (<21 >years) with a diagnosis of Crohn’s disease. Diagnoses and procedures were analyzed according to a recorded diagnosis of noncompliance. Multivariable logistic regression analysis was performed to examine the association between noncompliance and the outcomes of interest. Results: There were 28,337 pediatric Crohn’s disease hospitalizations identified with 1,028 (3.6%) hospitalizations having a diagnosis of both Crohn’s disease and noncompliance. The mean age of the study population was 15.9 years and 48.9% were girls. Black patients ( multivariable adjusted odds ratio, aOR,2.27; 95% CI:1.84-2.79) and those in the lowest income quartile (aOR 1.57; 95% CI:1.20-2.05) had an increased likelihood of a noncompliance diagnosis than respective comparison groups. Noncompliant patients had an increased likelihood of concurrent depression, nutritional deficiency, and anemia. Patients with a diagnosis of noncompliance had lower rates of intestinal obstruction (4.0% vs 6.3%), intraabdominal abscesses (2.0% vs 4.2%,), and underwent fewer major surgical procedures (aOR 0.40; 95% CI:0.31-0.53) and large bowel resections (aOR 0.44; 95% CI:0.31-0.64) than patients without this diagnosis. Conclusions: We found significant differences in socioeconomic status and race among hospitalized children with Crohn’s disease with, as compared to those without, a diagnosis of noncompliance. Children with noncompliance have different comorbidities, disease-related complications, and are managed differently. Possible explanations for observed treatment differences include a reluctance to offer surgery to those with a diagnosis of noncompliance, a refusal of intervention by noncompliant patients, or implicit bias. Further investigation is warranted to better define noncompliance in this population and to determine the implications of this diagnosis.

Background: Statins have questionable benefits among older adults with life-limiting illness. Statin use is widespread among U.S. older adults, but little is known about use in nursing homes. This dissertation was designed to identify the prevalence and predictors of statin pharmacotherapy use and discontinuation in U.S. nursing homes. Methods: Data sources (2011-2016) included: Minimum Data Set 3.0, Medicare administrative claims data, Provider of Service files, and Dartmouth Atlas files. Analyses included: descriptive statistics, multilevel modeling, and proportional change in cluster variations with adjustments to reduce confounding and model misspecification. Results: Approximately 36% of older adults admitted to U.S. nursing homes between 2015 – 2016 were actively using statins at the time of admission. Among long-stay residents with life-limiting illness, 34% were on statins at one time (2016; aged 65-75 years: 44%, >75 years: 31%). Statin use varied significantly by hospital referral regions, with most variation in the >75 age group. Limiting the sample to statin users, 20% discontinued statins within 30 days of nursing home admission. While discontinuation was positively associated with severity of life-limiting condition, the majority of residents remained on statins 30 days post-admission, including those with a < 6-month prognosis. Conclusion: Statin use is pervasive across US nursing homes and persists with life-limiting illness. Geographic variation appeared to coincide with clinical uncertainty, especially among adults >75 with few national guidelines. More needs to be done to prioritize statin deprescribing in nursing homes with research that identifies ways to facilitate improved patient-provider awareness and engagement in the discontinuation process.

Background Monoclonal Gammopathy of Undetermined Significance (MGUS) is an understudied precursor of multiple myeloma (MM), the second most prevalent hematologic malignancy in the United States. This dissertation was designed to: (1) Describe the trajectories of serum biomarkers over time in patients with an MGUS diagnosis, (2) Determine if an MGUS diagnosis is associated with changes in healthcare service utilization, and (3) explore the patient- and provider-level drivers of healthcare utilization in patients with MGUS. Methods Data sources include health claims and electronic health records from a community-based population of patients seeking care in central Massachusetts and primary qualitative data collected from providers and patients’ interviews. The analyses included descriptive statistics, group-based trajectory modeling, conditional Poisson regression, and qualitative data analyses. Results (1) Three distinct multi-trajectory groups of creatinine and hemoglobin were identified. (2) The rates of emergency room, hospital, and outpatient visits were higher for patients with MGUS than patients without MGUS. (3) Patients have a basic understanding of MGUS; however, some patients feel anxiety, which may affect other aspects of their lives. Patients primarily see hematologists for follow-up care; other providers have less knowledge about MGUS. Conclusions Biomarker trajectories characterize specific subpopulations of patients with MGUS over time. We found that an MGUS diagnosis is associated with higher healthcare utilization, especially during the months surrounding the diagnosis date. Finally, our study suggests that some patients with MGUS may need psychosocial support services and identifies a gap in knowledge around caring for MGUS patients among primary care providers.

Versorgungsforschung untersucht die Wirkungen und Kosten der Kranken- und Gesundheitsversorgung unter Routinebedingungen und berücksichtigt dabei alle Aspekte der gesundheitlichen Beratung, Prävention und klinischen Versorgung. Als wesentliche Determinanten der Effektivität und Effizienz der medizinischen Versorgung fließen in Studien der Versorgungsforschung häufig auch die Rahmenbedingungen und die Organisation des Gesundheitswesens und der sozialen Sicherungssysteme ein. Versorgungsforschung stellt jedoch nicht nur die sogenannte „letzte Meile“ der Gesundheitsforschung dar, sondern generiert darüber hinaus neue Hypothesen für klinische und experimentelle Forschung und trägt damit als Translationsforschung auch zur Klärung von Erkrankungsursachen bei. Aufgrund ihrer zentralen Rolle in der Gesundheitsforschung und einer langjährigen Tradition in diesem Forschungsfeld ist Versorgungsforschung/Public Health neben regenerativer Medizin und Onkologie einer von drei Profilschwerpunkten der Medizinischen Fakultät Carl Gustav Carus an der Technischen Universität Dresden. So bestehen beispielsweise in den Bereichen Dermatologie/Allergologie, Klinische Pharmakologie, Arbeits- und Sozialmedizin, Psychiatrie, Innere Medizin, Orthopädie, Allgemeinmedizin und Neurochirurgie bereits überregional bekannte und renommierte Arbeitsgruppen im Bereich Versorgungsforschung am Standort Dresden. Zur weiteren Profilschärfung in diesem Forschungsbereich wurde im Juni 2011 an der Medizinischen Fakultät Carl Gustav Carus der TU Dresden ein neuer Lehrstuhl „Sozialmedizin und Versorgungsforschung“ eingerichtet. Eines der selbsterklärten Ziele ist es dabei, durch multiprofessionelle Vernetzung von methodischer und klinischer Expertise Innovationen zu entwickeln, zu evaluieren und nachhaltig in der Gesundheits- und Krankenversorgung umzusetzen. Dahinter steht das Primat, dass Versorgungsforschung auf hohem Niveau und mit dem Ziel einer evidenzbasierten Politikberatung letztlich nur im interdisziplinären Austausch zu sichern ist. Unter dem Titel „Versorgungsforschung - Standortbestimmung und Perspektiven“ zielt das 6. Symposium der AG Versorgungsforschung darauf ab, die Akteure der Versorgungsforschung der Medizinischen Fakultät und des Universitätsklinikums Dresden vorzustellen und untereinander sowie mit gesundheitspolitischen Entscheidungsträgern, gesetzlichen Krankenversicherungen, mit Wissenschaftlerinnen und Wissenschaftlern, Studierenden und allen weiteren Interessierten ins Gespräch zu kommen. Kolleginnen und Kollegen aus 20 Kliniken und Instituten des Universitätsklinikums und der Medizinischen Fakultät Dresden haben insgesamt 36 Poster eingereicht, die die vielen unterschiedlichen Facetten der Versorgungsforschung in Dresden präsentieren. Diese 36 Poster, deren Abstracts in dieser Publikation zusammengestellt sind, stehen im Zentrum des 6. Symposiums der AG Versorgungsforschung. Auch wenn eine eindeutige Zuordnung nicht in allen Fällen möglich ist, wurden die Beiträge unter den Überschriften „Versorgungsepidemiologie“, „Prävention/Früherkennung“, „Ambulante Versorgung“ und „Stationäre Versorgung“ in vier thematisch gegliederte Postersessions eingeteilt.:Impressum, Editorial, Programmübersicht, Abstracts Poster, Teil 1 Versorgungsepidemiologie/ Sekundärdatenanalyse, Teil 2 Prävention/ Früherkennung, Teil 3 Ambulante Versorgung, Teil 4 Stationäre Versorgung, Autorenindex

Rural counties in the United States vary drastically on metrics related to socioeconomic status and dominant economic industry as well as health behaviors and outcomes. This study sought to understand the underlying structural reasons why some rural counties have better or worse than expected health outcomes using a positive deviance (PD) approach. The study aimed to: 1) create an area deprivation index and divide counties into quartiles using the index; 2) identify positive, negative, and non-deviant counties using health outcome metrics; 3) analyze differences between deviance on a variety of local public health system metrics; and 4) analyze differences between deviance on a variety of health service system metrics. All data were secondary, with data on public health systems derived from NACCHO’s 2016 National Profile of Local Health Departments (LHDs) and data on healthcare systems derived from HRSA’s 2016-2017 Area Health Resource File. Multivariate analysis, nonparametric analysis, and multinomial logistic regression were conducted. Results indicated that public health systems in positive deviant counties were more likely to have their next year’s budget exceed their current budget compared to negative and non-deviant counties. Public health systems in negative deviant counties had much lower rates of completed community health assessments, community health improvement plans, and strategic plans. LHDs overseen by their local government were 6.20 (p=.001) times more likely to be positive deviant, and negative deviant counties were much less likely (OR=0.12, pp 17.28 physicians per 10,000 population), while negative deviant counties were less likely (OR=.35, pp=.38) compared to non-deviant counties. Future research should continue using the PD approach for population-level studies and seek to understand which components of local public health and healthcare systems are associated with better population health.

Background Youth and young adults represent a critical time for early detection and intervention of serious mental health conditions (SMHCs); however, of all age groups, health care use is lowest in young adults. Continued access to health services such as outpatient primary care and specialized mental health care, especially during the transition from pediatric to adult care, is important to improving outcomes in those with serious mental health conditions. Methods Stakeholder engagement and a mixed-method design were used. Quantitative Aims 1 and 2 used the IBM MarketScanCommercial Database. Qualitative Aim 3 used semi-structured interviews with a purposive sample of pediatricians and child/adolescent psychiatrists. Stakeholders were engaged throughout all Aims to ensure relevance of goals, real-world interpretation of results, and dissemination of key findings. Aim 1 described patterns of outpatient (e.g., primary, reproductive, mental health care) and acute (e.g., emergency room use, inpatient hospitalization) health care use by age, and serious mental health condition for youth and young adults. Aim 2 used logistic models with generalized estimating equations to identify factors associated with mental health follow-up after hospitalization and emergency room use for a serious mental health condition. Aim 3 explored pediatrician and child/adolescent psychiatrist perspectives on coordinated care for youth and young adults with serious mental health conditions, particularly as they transition to adult care. Main Results The prevalence of outpatient mental health care and primary care decreased with age, with a larger drop in primary care utilization. While 74.0-78.4% of those aged 12-17 years used both outpatient mental health care and primary care, 53.1-59.7% of those aged 18-27 years did. Differences were observed by mental health condition; those with schizophrenia and other psychotic disorders had the lowest rates of outpatient primary care use and the highest rates of acute care use. Of those hospitalized, 42.7% received follow-up within 7 days and 64.7% within 30 days. Of those with emergency room use not resulting in a hospitalization, 28.6% received follow-up within 7 days and 46.4% within 30 days. Having established mental health care strongly predicted follow-up, and more so than having established primary care. Providers described poor communication systems, no organized process for the transition from pediatric to adult care, a lack of time and reimbursement, and inadequate connection to community supports as key barriers to continuous, coordinated care for youth with serious mental health conditions. Conclusion Findings provide foundational knowledge to inform efforts to provide a comprehensive continuum of care for people with serious mental health conditions, potentially through increased access to primary care and specialized mental health care via enhanced care coordination of providers.