Disaster events have emphasized the importance of healthcare response activities due to the large number of victims. For instance, Hurricane Katrina in New Orleans, in 2005, and the terrorist attacks in New York City and Washington, D.C., on September 11, 2001, left thousands of wounded people. In those disasters, although hospitals had disaster plans established for more than a decade, their plans were not efficient enough to handle the chaos produced by the hurricane and terrorist attacks. Thus, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) suggested collaborative planning among hospitals that provide services to a contiguous geographic area during mass casualty disasters. However, the JCAHO does not specify a methodology to determine which hospitals should be included into these cooperative plans. As a result, the problem of selecting the right hospitals to include in exercises and drills at the county level is a common topic in the current preparedness stages. This study proposes an efficiency index to determine the efficient response of cooperative-networks among hospitals before an occurrence of mass casualty disaster. The index built in this research combines operations research techniques, and the prediction of this index used statistical analysis. The consecutive application of three different techniques: network optimization, data envelopment analysis (DEA), and regression analysis allowed to obtain a regression equation to predict efficiency in predefined hospital networks for mass casualty disasters. In order to apply the proposed methodology for creating an efficiency index, we selected the Orlando area, and we defined three disaster sizes. Then, we designed networks considering two perspectives, hub-hospital and hub-disaster networks. In both optimization network models the objective function pursued to: reduce the iii travel distance and the emergency department (ED) waiting time in hospitals, increase the number of services offered by hospitals in the network, and offer specialized assistance to children. The hospital network optimization generated information for 75 hospital networks in Orlando. The DEA analyzed these 75 hospital networks, or decision making units (DMU's), to estimate their comparative efficiency. Two DEAs were performed in this study. As an output variable for each DMU, the DEA-1 considered the number of survivors allocated in less than a 40 miles range. As the input variables, the DEA-1 included: (i) The number of beds available in the network; (ii) The number of hospitals available in the network; and (iii) The number of services offered by hospitals in the network. This DEA-1 allowed the assignment of an efficiency value to each of the 75 hospital networks. As output variables for each DMU, the DEA-2 considered the number of survivors allocated in less than a 40 miles range and an index for ED waiting time in the network. The input variables included in DEA-2 are (i) The number of beds available in the network; (ii) The number of hospitals available in the network; and (iii) The number of services offered by hospitals in the network. These DEA allowed the assignment of an efficiency value to each of the 75 hospital networks. This efficiency index should allow emergency planners and hospital managers to assess which hospitals should be associated in a cooperative network in order to transfer survivors. Furthermore, JCAHO could use this index to evaluate the cooperating emergency hospitals’ plans. However, DEA is a complex methodology that requires significant data gathering and handling. Thus, we studied whether a simpler regression analysis would substantially yield the same results. DEA-1 can be predicted using two regression analyses, which concluded that the average distances between hospitals and the disaster locations, and the size of the disaster iv explain the efficiency of the hospital network. DEA-2 can be predicted using three regressions, which included size of the disaster, number of hospitals, average distance, and average ED waiting time, as predictors of hospital network efficiency. The models generated for DEA-1 and DEA-2 had a mean absolute percent error (MAPE) around 10%. Thus, the indexes developed through the regression analysis make easier the estimation of the efficiency in predefined hospital networks, generating suitable predictors of the efficiency as determined by the DEA analysis. In conclusion, network optimization, DEA, and regressions analyses can be combined to create an index of efficiency to measure the performance of predefined-hospital networks in a mass casualty disaster, validating the hypothesis of this research. Although the methodology can be applied to any county or city, the regressions proposed for predicting the efficiency of hospital network estimated by DEA can be applied only if the city studied has the same characteristics of the Orlando area. These conditions include the following: (i) networks must have a rate of services lager than 0.76; (ii) the number of survivors must be less than 47% of the bed capacity EDs of the area studied; (iii) all hospitals in the network must have ED and they must be located in less than 48 miles range from the disaster sites, and (iv) EDs should not have more than 60 minutes of waiting time. The proposed methodology, in special the efficiency index, support the operational objectives of the 2012 ESF#8 for Florida State to handle risk and response capabilities conducting and participating in training and exercises to test and improve plans and procedures in the health response.

Esta tese trata da questão dos municípios metropolitanos, na perspectiva da política nacional e regional de saúde conduzida pelo SUS. O trabalho enfatiza as dificuldades para solução metropolitana de regulação do sistema público de saúde, no contexto de crescente autonomia dos governos municipais e do enfraquecimento do poder dos governos estaduais. A política de regionalização e conformação de redes implementada pelo Ministério da Saúde desconhece as especificidades das diversas regiões metropolitanas do país. A tese explora, portanto, as contradições na política de descentralização face à Região Metropolitana, estudando duas questões centrais, a partir da análise da rede hospitalar na Região Metropolitana do Rio de Janeiro. Por um lado, busca verificar se a descentralização efetivamente propiciou o atendimento básico hospitalar dos pacientes em seus locais de residência, cabendo referenciar para outras localidades apenas os casos de alta complexidade, no caso para a capital, cidade do Rio de Janeiro, que apresenta rede hospitalar mais complexa. Por outro, levanta a questão das relações entre o contexto metropolitano e a necessidade de formação de uma rede integrada de serviços de saúde, abordando aspectos favoráveis e os obstáculos a esta necessária institucionalização. Este estudo é uma contribuição para o entendimento da questão metropolitana na área da saúde, de forma a permitir ultrapassar os obstáculos que impedem ações coletivas. / This thesis approaches metropolitan municipalities, within the perspective of the Brazilian National Health System . The work emphasizes the difficulties to regulate the public health system in the context of increased autonomy of municipal governments and weakened state governments. The regionalization politics and networks organization implemented by the Health Ministry ignores the specificities of the several Brazilian metropolitan regions. The thesis explores the contradictions between municipal decentralization politics and Metropolitan Region, analyzing two central issues, based on the analysis of the hospital network of Rio de Janeiro Metropolitan Region. It aims to verify whether decentralization really provided primary hospital care for patients in their neighboring areas, that is, whether municipalities provided primary admissions for their inhabitants, referring them to other cities mainly Rio de Janeiro city, owner of more complex health services network only in case of real necessity. Besides, it deals with the institutional challenge of creating an integrated municipal health care network in the metropolitan context. This study aims to increase knowledge on metropolitan health, helping to overcome obstacles to the development of collective actions concerning public health services planning and provision.

Esta tese trata da questão dos municípios metropolitanos, na perspectiva da política nacional e regional de saúde conduzida pelo SUS. O trabalho enfatiza as dificuldades para solução metropolitana de regulação do sistema público de saúde, no contexto de crescente autonomia dos governos municipais e do enfraquecimento do poder dos governos estaduais. A política de regionalização e conformação de redes implementada pelo Ministério da Saúde desconhece as especificidades das diversas regiões metropolitanas do país. A tese explora, portanto, as contradições na política de descentralização face à Região Metropolitana, estudando duas questões centrais, a partir da análise da rede hospitalar na Região Metropolitana do Rio de Janeiro. Por um lado, busca verificar se a descentralização efetivamente propiciou o atendimento básico hospitalar dos pacientes em seus locais de residência, cabendo referenciar para outras localidades apenas os casos de alta complexidade, no caso para a capital, cidade do Rio de Janeiro, que apresenta rede hospitalar mais complexa. Por outro, levanta a questão das relações entre o contexto metropolitano e a necessidade de formação de uma rede integrada de serviços de saúde, abordando aspectos favoráveis e os obstáculos a esta necessária institucionalização. Este estudo é uma contribuição para o entendimento da questão metropolitana na área da saúde, de forma a permitir ultrapassar os obstáculos que impedem ações coletivas. / This thesis approaches metropolitan municipalities, within the perspective of the Brazilian National Health System . The work emphasizes the difficulties to regulate the public health system in the context of increased autonomy of municipal governments and weakened state governments. The regionalization politics and networks organization implemented by the Health Ministry ignores the specificities of the several Brazilian metropolitan regions. The thesis explores the contradictions between municipal decentralization politics and Metropolitan Region, analyzing two central issues, based on the analysis of the hospital network of Rio de Janeiro Metropolitan Region. It aims to verify whether decentralization really provided primary hospital care for patients in their neighboring areas, that is, whether municipalities provided primary admissions for their inhabitants, referring them to other cities mainly Rio de Janeiro city, owner of more complex health services network only in case of real necessity. Besides, it deals with the institutional challenge of creating an integrated municipal health care network in the metropolitan context. This study aims to increase knowledge on metropolitan health, helping to overcome obstacles to the development of collective actions concerning public health services planning and provision.