The U.S. healthcare system is facing many public health challenges that affect population health, societal well-being, and quality of healthcare. Infant mortality, opioid overdose death, and hospital readmission after stroke are some of these important public health concerns that can impact the effectiveness and outcomes of the healthcare system. We analyze these problems through the industrial engineering and data analytics lens. The major goal of this dissertation is to enhance understanding of these three challenges and related interventions using different levels of analysis to improve the health outcomes. To attain this objective, I introduced three stand-alone papers to answer the related research questions. In essay 1, we focused on the performance of the state's healthcare systems in reducing unfavorable birth outcomes such as infant mortality, preterm birth, and low birthweight using Data Envelopment Approach. We constructed a unique state-level dataset to answer this main research question: what does make a healthcare system more successful in improving the birth outcomes? Our results indicated that socioeconomic and demographic factors may facilitate or obstruct health systems in improving their outcomes. We realized that states with a lower rate of poverty and African-American women were more successful in effectively reduce unfavorable birth outcomes. In the second essay, we looked into the trends of the opioid overdose mortalities in each state from 2008 to 2017. We investigated the effect of four state laws and programs that have been established to curb the epidemic (i.e., dose and duration limitations on the initial prescription, pain management clinic laws, mandated use of prescription drug monitoring programs, and medical cannabis laws) in short and long-term, while we controlled for several protentional risk factors. The results of fixed-effect regression and significant tests indicated that state policies and laws were unlikely to result in an immediate reduction in overdose mortalities and comprehensive interventions were needed to restrain the epidemic. The third essay investigated the risk factors of 30-day readmission in patients with ischemic stroke at an individual level. We aimed to identify the main risk factors of stroke readmissions and prioritized them using machine learning techniques and logistic regression. We also introduced the most effective predictive model based on different performance metrics. We used the electronic health records of stroke patients extracted from two stroke centers within the Geisinger Health System from 2015 to 2018. This data set included a comprehensive list of clinical features, patients' comorbidities, demographical characteristics, discharge status, and type of health insurance. One of the major findings of this study was that stroke severity, insert an indwelling urinary catheter, and hypercoagulable state were more important than generally known diagnoses such as diabetes and hypertension in the prediction of stroke 30-day readmission. Furthermore, machine learning-based models can be designed to provide a better predictive model. Overall, this dissertation provided new insights to better understand the three major challenges of the U.S. healthcare system and improve its outcomes. / Doctor of Philosophy / The major goal of a healthcare system can be summarized in three main objectives: preventing preterm birth and premature mortality, advancing the quality of life, and preparing for a good death. Despite all the national efforts to achieve these goals, the U.S. healthcare system still faces many obstacles and crises and suffers from inefficiencies. The U.S. infant mortality rate is still higher than any other comparable advanced country. The opioid overdose death rate has been steadily increasing since 1999 and has risen exponentially in recent years. Hospital readmissions especially in stroke patients impose a substantial cost burden on the healthcare system in the U.S. Also, readmitted stroke patients are at higher risk of mortality compared to the first admission. I believe that industrial engineering and data analytics approaches can help in advancing the understanding of these health challenges, their important risk factors, and effective interventions. In this dissertation, the main focus was on the performance, trends, variations, and processes of the healthcare systems. We applied innovative methods to provide answers to the following questions in three essays: What does make a healthcare system more successful in improving the birth outcomes? What factors do explain mortality from opioid painkillers? What are the determinants of state variations in mortalities from an opioid overdose? What is the impact of states' laws and programs and opioid prescription rates and overdose mortality rates? What are the most important contributors to stroke readmissions? The results of the first essay showed that not all the state's healthcare systems perform the same in terms of reducing unfavorable birth outcomes. States with lower people in poverty and lower African American women were more successful in improving their birth outcomes. The second study revealed that states with a higher share of uninsured people and binge drinkers were suffering from higher opioid overdose deaths. Also, our results implied that in addition to upstream prevention policies, states need to implement downstream programs to curb the epidemic. Finally, the third study showed that the top predictors of stroke readmissions within 30 days consist of the severity of the stroke, insert an indwelling urinary catheter, being overweight, and malnourished. The results of this dissertation can help to educate policymakers and practitioners at state and organizational level in a way to better serve the society and ultimately enhance the population health, quality of healthcare, and societal well-being.

The objectives of this study are to provide a comprehensive assessment of inequalities in infant and under-five years' child survival, access to and utilisations of child health services among different socio-economic groups in Ethiopia; and identify issues for policies and programmes at national and sub-national levels. This thesis examines the effect of parental socioeconomic status, maternal and delivery care services, mothers' bio-demographic and background characteristics on the level of differences in infant and under-five years' child survival and access to and utilisation of child health services. Descriptive and multivariate analyses were carried out for selected variables in the literature which were consider as the major determinants of infant mortality rate (IMR) and under-five years' child mortality rate (U5MR); access to and utilisations of child health services based on data from Ethiopian demographic and health survey (EDHS), covering the years 2000-2005. In the multivariate analysis a logit regression model was used to estimates inequalities in infant and under-five years' child survival, and inequalities in access to and utilisation of child health services. In Ethiopia, little was known about inequalities in IMR and U5MR, and inequalities in access to and utilisation of child health services. Besides, there is no systematic analysis of health inequalities and into its determinants using logistic regression. According to the available literature, this is the first comprehensive and systematic analysis of inequality of health in Ethiopia. The findings show that compared to under-five years' children of mothers' partners with no work, mothers' partners in professional, technical and managerial occupations had 13 times more chance of under-five years child survival for 2000 weighted observations. In addition, compared to infants of mothers who were gave birth to one child in last 5 years preceding the survey, infants of mothers who were gave birth to 2 children in last 5 years preceding the survey had 70% less chance of infant survival while infants of mothers who were gave birth to 3 or more children had 89% less chance of infant survival for 2000 weighted observations. Moreover, this study finding also indicates that inequalities increased significantly in the five years period between 2000 and 2005 among mothers with different birth interval. Most of the relations between birth interval and receiving childhood immunisation for vaccine-preventable diseases were statistically significant. Moreover compared to non-educated mothers, mothers who completed secondary and higher education were nearly 10 times more likely to receive DPT3 immunisation for their young children. This study concludes that policy measures that tackle health inequalities will have a positive impact in the implementation of health sector strategy of Ethiopia. Health inequalities studies in Ethiopia and Sub-Saharan Africa (SSA) countries should focus on systematic analysis of different socio-economic groups. The finding of this study support investing in the Ethiopia's health extension package (HEP) is a necessary but not sufficient condition for addressing rural poor health problem. HEP is successful in increasing primary health care coverage in rural Ethiopia to 89.6% (FMOH, 2009) but unable to reduce Ethiopia's higher level of IMR and U5MR. HEP is one of the success stories that address the rural poor health problem and can also be adapted to developing countries of SSA. The finding also shows that the success stories such as health insurance programs like Rwanda (World Bank, 2008a) and Ethiopia (FMOH, 2009/10) will play a key role in achieving country's health care financing goal of universal coverage. This can also be replicated in the developing SSA countries.

<p>Uvod: Bronhopulmonalna displazija (BPD) je najče&scaron;ća i najteža respiratorna posledica prematuriteta. Utvrđivanje najznačajnijih faktora rizika za nastanak BPD kod novorođenčadi porođajne mase (PM) ispod 1500g može omogućiti procenu rizika za&nbsp; nastanak bolesti i identifikaciju novorođenčadi u visokom riziku, &scaron;to je važno za pružanje informacija roditeljima o prognozi,&nbsp; planiranje preventivnih i terapijskih mera i stratifikovanje novorođenčadi koja su u riziku za sprovođenje budućih istraživanja. Cilj: Utvrđivanje incidencije, stepena težine BPD, smrtnosti, identifikacija najznačajnijih prenatalnih i postnatalnih faktora rizika za nastanak BPD, konstrukcije modela predikcije za nastanak BPD. Materijal i metode: Istraživanje je sprovedeno na 504&nbsp; prevremeno rođene novorođenčadi PM&lt;1500g koja su rođena u porodili&scaron;tima u AP Vojvodini i lečena u tercijarnom Centru za neonatologiju i intenzivnu negu i terapiju, na Institutu za zdravstvenu za&scaron;titu dece i omladine Vojvodine u periodu od&nbsp; 2006.-2011. godine. Retrospektivno je analizirano prisustvo BPD, prema stepenima težine, smrtnost. Podaci su izdvojeni iz&nbsp; istorija bolesti za svako novorođenče, 30 potencijalnih prenatalnih i postnatalnih faktora je opisano deskriptivnom i univarijantnom statistikom. Statstički najznačajniji faktori su uneti u multifaktorsku logističku regresionu analizu u cilju&nbsp; konstrukcije prediktivnih modela za nastanak BPD u 1.,14. i 21. danu neonatalnog života. Podaci su obrađeni u StatSoft-ovom&nbsp; programskom paketu Statistica 10.0.&nbsp; Validacija modela predikcije je sprovedena u prospektivnom delu istraživanja, na 100&nbsp;&nbsp;&nbsp; prevremeno rođene novorođenčadi&lt;1500g, u periodu od 2012-2013. godine. Rezultati: U retrospektivnom delu&nbsp; istraživanja,&nbsp; od 504&nbsp; novorođenčeta PM&lt;1500 grama, umrlo je 17.65%, BPD je imalo 45.43% (blagu BPD 19.44%, srednje te&scaron;ku 19.84%,&nbsp; te&scaron;ku&nbsp; 6.15%), srednje te&scaron;ku i&nbsp; te&scaron;ku 25.99%.Antenatalna primena kortikosteroida je zastupljena u 47.02%, surfaktant&nbsp;&nbsp; je&nbsp;&nbsp; primenjen kod 69.78% novorođenčadi. Najznačajniji prenatalni prediktivni faktor rizika za nastanak BPD/smrtnog ishoda je horioamnionitis (OR 5.72; 95% CI 3.42-9.62), dok su protektivni faktori: prenatalna primene kortikosteroida (OR&nbsp; 0.41;&nbsp; 95%CI&nbsp; 0.29-0.60), porođaj carskim rezom (OR&nbsp; 0.24; 95% CI 0.16-0.36). Najznačajniji&nbsp; postnatalni prediktivni faktori rizika su: GS&nbsp; (p&asymp;0.00), PM (p&asymp;0.00), reanimacija u porođajnoj sali (OR 7.01; 95% CI 4.12-12.01), rana&nbsp; neonatalna&nbsp; sepsa&nbsp; (OR&nbsp; 7.35;&nbsp; 95%CI&nbsp; 3.79-14.58), RDS&nbsp; (p&asymp;0.00), primena surfaktanta (OR13,3;95%CI 8,2 - 21,67), DAP (OR 4.12; 95%CI&nbsp; 2.47-6.89),&nbsp; dok&nbsp; je&nbsp; ženski&nbsp; pol&nbsp; protektivan (OR&nbsp; 0.61; 95% CI 0.42-0.89). FiO2 i IPPV su u svim posmatranim danima značajni faktori rizika. Primena IPPV u 1. danu (OR 10.71;&nbsp; 95% CI 6.67-17.26); u ostalim danima rizik od BPD raste prema rastućoj invazivnosti respiratorne&nbsp; potpore.&nbsp; Konstruisani su modeli&nbsp; predikcije za 1, 14 i 21. dan života, modeli imaju visoku prediktivnu vrednost: ukupan procenat uspe&scaron;nosti&nbsp; modela je 84.26%-90.80%, modeli sa ne&scaron;to većim uspehom predviđaju&nbsp;&nbsp; prisustvo (85.36%-94.12%), nego odusustvo BPD (81.72-86.56%). OR modela je 28.07-103.04. Modeli su uspe&scaron;no validirani&nbsp; na 102 pacijenta sa ukupnim procentom uspe&scaron;nosti (82-90%), PPV (0.86-0.94) i NPV (0.76-0.87). Zaključak:&nbsp; Kori&scaron;ćenjem&nbsp; prenatalnih i postnatalnih kliničkih podataka moguće je predvideti nastanak BPD ili smrtnog ishoda.</p> / <p>Introduction: Bronchopulmonary dysplasia (BPD) is the most common serious pulmonary morbidity in very low birth weight (VLBW) infants. It is of clinical importance to determine clinical variables that are associated with BPD in order to identify infants who are at risk of developing BPD; it contributes to BPD prevention, may enable prognostic information for parents and future studies design. Objective: The aim of this study was to determine the incidence and severity of BPD, mortality rate in VLBW infants, to identify prenatal and postnatal predictive risk factors for bronchopulmonary dysplasia and competing outcome of death and to develop predictive models. Materials and Methods: Study was conducted in 504 VLBW infants born in the maternity hospitals in Vojvodina and admitted to tertiary Center for newborn and neonatal intensive care at the Institute for Child and Youth Health Care of Vojvodina, from January 2006. to December 2011. Data were retrospectively collected from clinical records for outcomes BPD or death; prenatal and postnatal factors associated with BPD were collected at three postnatal ages and examined by descriptive and univariate statistics; factors that were significantly associated with BPD and/or death were entered into a multivariate logistic regression analysis for develop predictive models. Data were analyzed using StatSoft&#39;s software package Statistica 10.0. Validation of the models were conducted in a prospective study in 102 VLBW infants born from January 2012. to December 2013. Results: There were 504 very low birth weight infants who were eligible for this study, 17.65% died, 45.43% developed BPD (mild BPD 19.44%, moderate 19.84%, severe 6.15%), moderate and severe 25.99%. The mean birth weight for the cohort was 1125.6&plusmn;280.9g, the mean gestation age was GS 28,78&plusmn;3,01, 49.21% were male. Surfactant received 69.78%, antenatal steroids 47.02% newborns. Key risk factors for BPD and/or death were: chorioamnionitis and maternal infections at delivery (OR 5.72; 95% CI 3.42-9.62); protective prenatal factors were: antenatal corticosteroid therapy (OR 0.41; 95%CI 0.29-0.60), cesarean delivery (OR 0.24; 95% CI 0.16-0.36). Postnatal rick factors were: GS (p&asymp;0.00), birth weight (p&asymp;0.00), delivery room resuscitation (OR 7.01; 95% CI 4.12-12.01), early neonatal sepsis (OR 7.35; 95%CI 3.79-14.58), RDS (p&asymp;0.00), surfactant (OR13,3;95%CI 8,2 - 21,67), DAP (OR4.12; 95% CI 2.47-6.89), while female gender was protective (OR 0.61; 95% CI 0.42-0.89). At each time point studied, FiO2 was significantly higher in BPD/death, as well as respiratory support; on the first day invasive respiratory support was significantly associated with BPD/death (IPPV and HFOV) (OR 10.71; 95% CI 6.67-17.26), in other days BPD was associated with increasing invasiveness of respiratory support. In multifactorial logistic regression analysis separately predictive models were developed at three postnatal ages, at 1st, 14th and 21st day. Models had high predictive performance: total success of the models were 84.26% - 90.80%, models successfully predicted the presence of BPD in 85.36% -94.12%, absence of the BPD in 81.72 - 86.56% cases. OR of models were 28.07-103.04. The models were successfully validated on 102 patients with a total percentage of success 82 - 90%, with PPV 0.86-0.94 and NPV 0.76-0.87. Conclusion: Using prenatal and postnatal clinical data it is possible to predict the development of BPD and/or death in very low birth weight infants. It is very important to identify risk factors for BPD development in order to decrease the incidence of BPD and mortality rate.</p>

L'existence des inégalités sociale de santé (ISS) est solidement établie en France. La mortalité infantile et néonatale sont reconnues comme des indicateurs de l'état de santé d'une population. En dépit de nombreux facteurs de risques déjà identifiés, une part des ISS demeurent inexpliquées ; les nuisances environnementales sont suspectées. L'objectif de la thèse est d'analyser par une approche spatio-temporelle la contribution de l'exposition au dioxyde d'azote aux inégalités sociales de mortalité infantile et néonatale en France 2000-2009. L'étude est épidémiologique de type écologique dans les agglomérations de Lille, Paris, Lyon, et Marseille. L'unité géographique est l'IRIS. Les cas recueillis dans les mairies ont été géocodés en utilisant l'adresse de résidence des parents. Les données socioéconomiques estimées à partir des recensements de 1999, 2006 ont été utilisées dans un indice composite définissant la défaveur socioéconomique globale. Les concentrations moyennes de dioxyde d'azote ont été modélisées par les réseaux de surveillance de la qualité de l'air. Des modèles statistiques additifs généralisés ont permis de prendre en compte l'autocorrélation spatiale et de générer des cartes à l'aide de lissage sur la longitude et la latitude tout en ajustant sur les variables d'intérêt. A l'aide d'une approche innovante, les résultats ont démontré l'existence de zones d'inégalités socio-spatiales, environnementale ou le cumul d'inégalités de mortalité infantile et néonatale. Ces résultats sont ville-spécifique, ils varient selon la période d'étude et l'évènement sanitaire étudié démontrant ainsi la difficulté de généraliser ces observations à l'échelle nationale / In France, existence of social health inequalities (SHI) has well established. Infant and neonatal mortality are recognized as indicators of the health status of a population. In spite of numerous risk factors already identified, a part of these inequalities remain unexplained, environmental nuisances are suspected. The thesis objectives were to analyze by a spatial and temporal approach, the contribution of exposure to nitrogen dioxide to social inequalities in infant and neonatal mortality in France between 2000 and 2009. We conducted an ecological type epidemiological study using the French census block as the geographical unit in the metropolitan areas of Lille, Paris, Lyon, and Marseille. All cases collected in the cities hall were geocoded using address of parent's residence. Socioeconomic data estimated from the 1999, 2006 national census were used in a composite index which encompasses multiple dimensions to analyze global deprivation. Average nitrogen dioxide concentrations were modeled by the air quality monitoring networks. Generalized additive models allowed to take into account spatial autocorrelation and generate maps using smoothing on longitude and latitude while adjusting for covariates of interest. Using an innovative approach, results highlight the existence of socio-spatial, environmental or cumulate inequalities in infant and neonatal mortality. These results are city-specific, they vary according to the period and the health event demonstrating the difficulty to generalize these observations at the national level

Submitted by Eunice Novais (enovais@uepg.br) on 2017-08-18T23:30:28Z No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Ana Paula Cavalheiro.pdf: 26595589 bytes, checksum: 21628d3cc713bc211eb950aaab0ae36c (MD5) / Made available in DSpace on 2017-08-18T23:30:28Z (GMT). No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Ana Paula Cavalheiro.pdf: 26595589 bytes, checksum: 21628d3cc713bc211eb950aaab0ae36c (MD5) Previous issue date: 2017-03-21 / O presente trabalho tem como objetivo descrever o processo de implementação da Rede Mãe Paranaense no município de Ponta Grossa, para verificar sua repercussão na mortalidade infantil. Trata-se de uma pesquisa interdisciplinar em ciências sociais aplicadas, cuja abordagem é qualiquantitativa do tipo exploratória e descritiva. Esta foi estruturada a partir de pesquisa bibliográfica, pesquisa documental, com recorte temporal entre os anos de 2012 a 2014, e pesquisa de campo, por meio de entrevistas semi-estruturadas junto a cinco participantes, que foram eleitos a partir da função que exerciam na gestão e implementação de ações da Rede Mãe Paranaense, nos meses de julho e agosto de 2016. O conteúdo das entrevistas, bem como os resumos e relatos dos óbitos, foram analisados pelo modelo da análise de conteúdo. Para fins organizacionais o trabalho foi dividido em quatro capítulos, sendo o primeiro intitulado “Concepções contemporâneas acerca do Estado, direitos e políticas públicas para o entendimento das políticas de enfrentamento à mortalidade infantil brasileiras”, que teve como objetivo trazer ao debate a origem do Estado Moderno e Contemporâneo, bem como a formação do Estado no Brasil. Esta abordagem antecedeu o debate sobre a origem e a efetivação dos direitos por meio das políticas públicas. O capítulo avança para o debate sobre a Política Social, a Política de Saúde e as Políticas de enfrentamento à mortalidade infantil brasileiras. O segundo capítulo, denominado “Mortalidade na Infância e Mortalidade Infantil” objetiva apresentar os conceitos de mortalidade infantil e mortalidade na infância, bem como apontar os perfis destes indicadores na realidade nacional e internacional. O terceiro capítulo, que tem como título “Redes de Atenção Materno Infantil” apresenta a conceituação, caracterização e operacionalização das Redes de Atenção à Saúde – RAS, bem como o marco conceitual da Rede Cegonha, em âmbito nacional, e da Rede Mãe Paranaense, em âmbito estadual. O quarto capítulo referenciado como “Percepções referentes à implementação da Rede Mãe Paranaense no município de Ponta Grossa e sua repercussão na mortalidade infantil sob a óticas dos participantes da pesquisa” objetiva apresentar a análise dos materiais coletados a partir de sua categorização. O que se evidencia na pesquisa realizada é que em função da fragmentação do processo de implementação da Rede Mãe Paranaense no município de Ponta Grossa, não se observaram reduções da mortalidade infantil no primeiro triênio após sua implantação, sobretudo entre os óbitos em menores de 06 dias de vida. Evidenciou-se ainda que fatores socioeconômicos e demográficos maternos são decisivos na ocorrência do óbito infantil no referido município. / The present work aims to describe the process of implementation of the Mãe Paranaense Network in the city of Ponta Grossa, to verify its repercussion on infant mortality. This is an interdisciplinary research in applied social sciences, whose approach is qualitative quantitative exploratory and descriptive. This study was structured based on bibliographic research, documentary research, with a temporal cut between the years of 2012 to 2014, and field research, through semi-structured interviews with five participants, who were elected based on their role in the Management and implementation of actions of Rede Mãe Paranaense in July and August 2016. The content of the interviews, as well as the summaries and reports of deaths, were analyzed by the content analysis model. For organizational purposes, the study was divided into four chapters, the first one entitled "Contemporary conceptions about the State, rights and public policies for the understanding of Brazilian child mortality coping policies", which aimed to bring the State's origin to the debate Modern and Contemporary, as well as the formation of the State in Brazil. This approach preceded the debate on the origin and realization of rights through public policies. The chapter advances to the debate on the Brazilian Social Policy, Health Policy and Policies to combat infant mortality. The second chapter, entitled "Mortality in Childhood and Infant Mortality", aims to present the concepts of infant mortality and infant mortality, as well as to indicate the profiles of these indicators in national and international reality. In the third chapter, which has the title "Networks of Maternal and Child Care" will be presented the conceptualization, characterization and operationalization of Health Care Networks - RAS, as well as the conceptual framework of the Stork Network, at the national level, and the Mãe Paranaense Network, At the state level. The fourth chapter referred to as "Perceptions regarding the implementation of the Mãe Paranaense Network in the city of Ponta Grossa and its repercussion on infant mortality from the perspective of the research participants" aims to present the analysis of the materials collected from their categorization. What is evidenced in the research carried out is that due to the fragmentation of the process of implementation of the Mãe Paranaense Network in the city of Ponta Grossa, there were no reductions in infant mortality in the first triennium after its implantation, especially among deaths in children under 06 days Of life. It was also evidenced that maternal socioeconomic and demographic factors are decisive in the occurrence of infant death in said municipality.

Submitted by Eunice Novais (enovais@uepg.br) on 2018-06-25T19:39:02Z No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Beatriz G Lopes.pdf: 1080092 bytes, checksum: 9fffda51f73cd69d456d2c8cc8714ac9 (MD5) / Made available in DSpace on 2018-06-25T19:39:02Z (GMT). No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Beatriz G Lopes.pdf: 1080092 bytes, checksum: 9fffda51f73cd69d456d2c8cc8714ac9 (MD5) Previous issue date: 2018-05-04 / Estudo qualitativo de natureza interpretativa realizado com mães que vivenciaram a perda de um filho no período perinatal, a fim de apresentar os cenários da mortalidade perinatal, de acordo com a perspectiva materna e evidências epidemiológicas. Os achados deste estudo indicam que 52% das mães participantes da pesquisa foram classificadas como de baixo risco gestacional ou risco intermediário e que 78,27% das mortes dos bebês eram evitáveis. Também, destaca-se que o processo do luto é contínuo, doloroso e perdura, e as dificuldades vivenciadas pelas mães evidenciam que as mesmas não são assistidas integralmente por uma equipe de saúde capacitada para ajudar nessa situação angustiante. Dessa maneira, evidencia a necessidade de uma rede de apoio no momento que a mãe recebe a notícia do óbito do seu filho e que esse cuidado perdure até que a enlutada encontre um significado para sua perda. Assim, conclui-se a importância de uma equipe interdisciplinar, para o cuidado integral e ainda, garantir uma assistência humanizada com qualidade. / A qualitative study of an interpretative nature performed with mothers who experienced the loss of a child in the perinatal period, in order to present the scenarios of perinatal mortality according to maternal perspective and epidemiological evidence. The findings of this study indicate that 52% of the mothers participating in the research were classified as having low gestational risk or intermediate risk and that 78.27% of infant deaths were avoidable. It is also noteworthy that the process of mourning is continuous, painful and lasting, and the difficulties experienced by the mothers show that they are not fully assisted by a health team trained to help in this distressing situation. In this way, it is evident the need for a support network the moment the mother receives the news of her child's death and that this care lasts until the bereaved finds a meaning for her loss. Thus, we conclude the importance of an interdisciplinary team, for the integral care and also, guarantee a humanized assistance with quality.

Orientador: Renato Passini Júnior / Tese (Doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-11-27T12:42:05Z (GMT). No. of bitstreams: 1 MachadoJunior_LuisCarlos_D.pdf: 2512679 bytes, checksum: 24dd4c071dfcdc0f3d90247ac2b8cd08 (MD5) Previous issue date: 2013 / Resumo: INTRODUÇÃO: A idade gestacional ao nascimento é um dos principais fatores associados com complicações e mortes neonatais. Crianças nascidas entre 34 semanas e 36 semanas e seis dias de idade gestacional, denominadas prematuros tardios, são, tradicionalmente, considerados como de risco e prognóstico muito semelhantes aos dos recém-nascidos a termo. Estudos mais recentes, porém, têm mostrado que tanto prematuros tardios, quanto aqueles nascidos entre 37 e 38 semanas, apresentam resultados neonatais e no primeiro ano de vida, significativamente piores que os dos recém-nascidos a partir de 39 semanas. OBJETIVOS: revisar a literatura sobre o tema, analisar a prevalência de nascimento de prematuros tardios no tempo e comparar a frequência de mortes e complicações neonatais nos prematuros tardios e nos nascidos entre 37 e 38 semanas, com as mortes e complicações neonatais dos recém-nascidos a partir de 39 semanas. MÉTODO: revisão de literatura englobando os bancos de dados Medline, Lilacs e Biblioteca Cochrane. Realizado estudo de coorte retrospectiva com os dados de recém-nascidos vivos atendidos no Centro de Atenção Integral à Saúde da Mulher (CAISM) da Universidade Estadual de Campinas (UNICAMP), de janeiro de 2004 a dezembro de 2010. Os dados foram extraídos a partir do arquivo eletrônico da instituição. Foram excluídos os casos sem informação sobre a idade gestacional, as malformações e doenças congênitas fetais e as gestações múltiplas. Além das mortes neonatais, foram estudadas as seguintes complicações: hemorragia do sistema nervoso central, convulsões, índice de Apgar menor que sete no primeiro e quinto minutos, pneumonia, atelectasia, displasia broncopulmonar, pneumotórax, laringite pós entubação, síndrome de aspiração de mecônio, hipotermia, hipocalcemia e icterícia. As variáveis de controle foram: idade materna, estado civil, tabagismo, realização de pré-natal, hipertensão arterial (pré eclampsia ou crônica), diabetes, infecção urinária, outras morbidades maternas, primiparidade, cinco ou mais partos anteriores, tipo de parto, crescimento fetal restrito e sexo do recém-nascido. Para análise estatística foi aplicado o teste de qui-quadrado e o teste exato de Fisher, quando indicado. Assumiu-se o valor de p menor que 0,05 como significâncias estatísticas. Foi utilizado odds ratio (OR) como medida de efeito e a regressão logística múltipla para a análise multivariada. RESULTADOS: Foram estudados 18.032 nascimentos únicos, sendo 1.653 prematuros tardios e 16.379 recém nascidos de termo. Houve mais mortes neonatais (OR ajustado = 5.30; IC 95%: 2,61?10,74) nos prematuros tardios em comparação com os recém-nascidos a termo (nascidos entre 37 e 42 semanas). Também houve mais mortes neonatais (OR ajustado = 2,44; IC 95% 1,05-5,63) nos recém-nascidos de termo precoce comparados aos de termo tardio. Houve associação significativa para todas as complicações estudadas com a prematuridade tardia, exceto para síndrome de aspiração de mecônio. Encontrou-se tendência significativa de aumento na proporção de prematuros tardios em relação ao total dos partos ao longo do período estudado. CONCLUSÃO: Conclui-se que tanto os prematuros tardios quanto os nascidos entre 37 e 38 semanas são uma população de maior risco se comparados aos recém-nascidos a partir de 39 semanas / Abstract: INTRODUCTION: Gestational age at birth is a major determinant of neonatal mortality and complications. The risk of death and complications in infants born at 34 to 36 weeks of pregnancy (named late preterm infants) has been traditionally considered to be very similar to that of term infants. Some recent studies, however, have shown that late preterm infants, as well as those born at 37 and 38 weeks, have significantly worse outcomes in the neonatal period and in the first year of life than those born at 39 weeks or later. OBJECTIVE: to conduct a literature review on this issue; assess the prevalence and any temporal trend in late preterm births in the period that was studied; to compare neonatal deaths and complications in late preterm infants versus term infants, and compare neonatal deaths in infants born at 37 and 38 weeks (early term) versus those born at 39 to 42 weeks (late term). METHODS: A retrospective cohort study of live births was carried out in the Women's Integrated Healthcare Center (CAISM), State University of Campinas (UNICAMP), from January 2004 to December 2010. Data were extracted from an electronic database containing all medical records of the institution. Excluded from the study were congenital diseases and malformations, multiple pregnancies and cases without data on gestational age. Outcomes studied were neonatal deaths, length of hospital stay and the following complications: central nervous system hemorrhage, convulsions, Apgar score lower than seven at the first and fifth minute, pneumonia, atelectasis, pneumothorax, bronchopulmonary dysplasia, pulmonary hypertension, postintubation laryngitis, meconium aspiration syndrome, hypothermia, hypocalcemia and jaundice. Control variables were: maternal age, marital status, smoking habit, and absence of prenatal care, maternal hypertensive disease, maternal diabetes, urinary tract infection, other maternal morbid condition, primiparity, five or more previous births, fetal growth restriction, fetal gender, labor induction and pre labor cesarean section. It was used the chi square test and Fischer's exact test when indicated. The odds ratio (OR) was used as a measure of effect and multiple logistic regression was used for multivariate analysis. A significant level of 5% was adopted. RESULTS: After exclusions, there were 18,032 single births (1,653 late preterm births and 16,379 term births). An adjusted OR of 5.30; 95% confidence interval of 2.61--- 10.74 was found for neonatal death in late preterm births compared to term births (at 37 to 42 weeks), and an adjusted OR of 2.44; 95 confidence interval of 1.05-5.63 for neonatal death in early term births compared to late term births. A significantly higher risk was found in late preterm infants compared to term infants for all complications studied, except for meconium aspiration syndrome. There was a significantly growing trend in the proportion of late preterm births at the institution in the period studied. CONCLUSION: It was concluded that late preterm infants are at higher risk of undesirable outcomes than term infants. Furthermore, early term infants have a higher risk of death compared to late term infants and these differences are clinically relevant / Doutorado / Saúde Materna e Perinatal / Doutor em Ciências da Saúde

Made available in DSpace on 2014-12-17T15:43:48Z (GMT). No. of bitstreams: 1 MatheusSM_DISSERT.pdf: 826650 bytes, checksum: 41c585f7d1d37e8e9af7b5caa4e9f50f (MD5) Previous issue date: 2012-12-21 / Investments in health have controversial influence on results of the health of populations, besides being subject rarely explored in literature. Moreover, from the 1970s, the social determinants of health have been consolidated in the disease process as multifactorial factors (social, economic, cultural, etc.) that directly or indirectly influence the occurrence of health problems of populations, as well as mortality rates. This study aimed to evaluate the influence of these investments and the social determinants of health on infant mortality and its neonatal and post-neonatal mortality. This is an ecological study, in which the sample was composed of Brazilians cities with over 80,000 inhabitants, avoiding fluctuations in mortality rates for common small populations, and ensure greater coverage of information systems on mortality and births Brazilians and, therefore, increase data consistency. To isolate the effect of investments in health, we used multiple linear regression. The socioeconomic indicators (p <0.001, p = 0.004, p <0.001), the inequality index (p <0.001, p = 0.001, p = 0.006) and coverage of prenatal visits (p <0.001, p <0.001; p = 0.005) were associated with infant mortality rate total, neonatal and post-neonatal, and the Gross Domestic Product per capita only influenced the overall infant mortality rate and neonatal (p=0.022; 0.045). Investments in health, in this model, lost statistical significance, showing no correlation with mortality rates among children under one year. We conclude that the social determinants of health has an influence on the variation in mortality rates of Brazilian cities, however the same was not observed for indicators of health investment / Os investimentos em sa?de possuem controversa influ?ncia nos resultados em sa?de das popula??es, al?m de serem temas pouco recorrentes na literatura. Por outro lado, a partir da d?cada de 1970, os determinantes sociais em sa?de se consolidaram no processo sa?dedoen?a como fatores multifacet?rios (sociais, econ?micos, culturais entre outros) que influenciam direta ou indiretamente a ocorr?ncia de agravos ? sa?de das popula??es, bem como as taxas de mortalidade. Esse estudo buscou avaliar a influ?ncia desses investimentos e dos determinantes sociais em sa?de sobre a taxa de mortalidade infantil e seus componentes neonatal e p?s-neonatal. Trata-se de um estudo ecol?gico, no qual a amostra foi composta por munic?pios brasileiros com mais de 80 mil habitantes, evitando-se, assim, flutua??es nas taxas de mortalidade comum para pequenas popula??es, al?m de garantir maior cobertura dos sistemas de informa??o sobre mortalidade e sobre nascidos vivos brasileiros e, com isso, aumentar a consist?ncia dos dados. Para isolar o efeito dos investimentos em sa?de, utilizouse a regress?o linear m?ltipla. Os indicadores socioecon?micos (p<0,001; p=0,004; p<0,001), o ?ndice de desigualdade (p<0,001; p=0,001; p=0,006) e a cobertura de consultas pr?-natal (p<0,001; p<0,001; p=0,005) apresentaram rela??o com a taxa de mortalidade infantil total, neonatal e p?s-neonatal, sendo que o Produto Interno Bruto per capita influenciou apenas a taxa de mortalidade infantil total e neonatal (p=0,022; 0,045). Os investimentos em sa?de, nesse modelo, perderam signific?ncia estat?stica, n?o apresentando correla??o com os ?ndices de mortalidade entre as crian?as menores de um ano. Conclui-se que os determinantes sociais de sa?de tem influ?ncia na varia??o das taxas de mortalidade dos munic?pios brasileiros, no entanto o mesmo n?o foi observado para os indicadores de investimento em sa?de

As informações de mortalidade são úteis para avaliar a situação de saúde de uma população. Dados de mortalidade confiáveis produzidos por um sistema de informação de saúde nacional constituem uma ferramenta importante para o planejamento de saúde. Em muitos países, sobretudo em desenvolvimento, o sistema de informação de mortalidade continua precário. Apesar dos esforços feitos em Moçambique para melhoria das estatísticas de mortalidade, os desafios ainda prevalecem em termos de tecnologias de informação, capacidade técnica de recursos humanos e em termos de produção estatística. O SIS-ROH é um sistema eletrônico de registro de óbitos hospitalares de nível nacional, implementado em 2008 e tem uma cobertura de apenas 4% de todos os óbitos anuais do país. Apesar de ser um sistema de nível nacional, ele presentemente funciona em algumas Unidades Sanitárias (US), incluindo o Hospital Central da Beira (HCB). Dada a importância deste sistema para monitorar o padrão de mortalidade do HCB e, no geral, da cidade da Beira, este estudo avalia a qualidade do SIS-ROH do HCB. É um estudo descritivo sobre a completitude, cobertura, concordância e consistência dos dados do SIS-ROH. Foram analisados 3.009 óbitos de menores de 5 anos ocorridos entre 2010 e 2013 e regsitrados no SIS-ROH e uma amostra de 822 Certificados de Óbitos (COs) fetais e de menores de 5 anos do HCB. O SIS-ROH apresentou uma cobertura inferior a 50% calculados com os dados de mortalidade estimados pelo Inquérito Nacional de Causas de Morte (INCAM). Verificamos a utilização de dois modelos diferentes de CO (modelo antigo e atual) para o registro de óbitos referentes ao ano de 2013. Observou-se completitude excelente para a maioria das variáveis do SISROH. Das 25 variáveis analisadas dos COs observou-se a seguinte situação: 9 apresentaram completitude muito ruim, sendo elas relativas à identificação do falecido (tipo de óbito e idade), relativas ao bloco V em que dados da mãe devem ser obrigatoriamente preenchidos em caso de óbitos fetais e de menores de 1 ano (escolaridade, ocupação habitual, número de filhos tidos vivos e mortos, duração da gestação) e relativas às condições e às causas de óbito (autópsia e causa intermédiacódigo); 3 variáveis apresentaram completitude ruim relativas à identificação do falecido (NID) e relativas às condições e causas de morte (causa intermédia - descrição e causa básica - código); 9 apresentaram completitude regular relativas à identificação do falecido (data de nascimento e idade), relativas ao bloco V (idade da mãe, tipo de gravidez, tipo de parto, peso do feto/bebé ao nascer, morte do feto/bebé em relação ao parto) e relativas às condições e causa de óbito (causa direta- código, causa básica descrição); 2 apresentaram completitude bom relativas à identificação do falecido (sexo e raça/cor) e, por último, 2 apresentaram completitude excelente relativas ao local de ocorrência de óbito (data de internamento e data de óbito ou desaparecimento do cadáver). Algumas variáveis do SIS-ROH e dos COS apresentaram inconsistências. Observou-se falta de concordância para causa direta entre o SIS-ROH e os COs. Conclusão: Moçambique tem feito esforços para aprimorar as estatísticas de mortalidade, porém há lacunas na qualidade; a análise rotineria dos dados pode identificar essas lacunas e subsidiar seu aprimoramento. / The mortality information is useful to assess the health status of a population. Reliable mortality data produced by a national health information system is an important tool for health planning. In many countries, especially developing countries, the mortality information system is still precarious. Despite efforts in Mozambique to improve mortality statistics, challenges still prevail in terms of information technology, technical capacity and human resources and statistical production. The SIS-ROH is an electronic system of national-level hospital deaths registration, implemented in 2008 and has a coverage of only 4% of all annual deaths in the country. Despite being a national system, it currently works in some health units (US), including Beira Central Hospital (HCB). Given the importance of this system to monitor the mortality pattern of HCB and, in general, the city of Beira, this study evaluates the quality of SIS-ROH HCB. It is a descriptive study on the completeness, coverage, compliance and consistency of the SIS-ROH data and examined a sample of 822 HCB deaths Certificates (COs) of fetal and children under 5 years of age. We find the use of two different models of CO (former and current model) for the registration of deaths related to the year 2013. We observed excellent completeness for most SIS-ROH variables. Of the 25 variables of COs there was the following situation: 9 had very bad completeness, which were relating to the identification of the deceased (type of death and age) on the V block in the mother\'s data, where must be filled in case of stillbirths and children under 1 year of age (education, usual occupation, number of living children taken and killed, gestational age) and on the conditions and causes of death (autopsy and intermediate-code causes); 3 variables had bad completeness concerning the identification of the deceased (NID) and on the conditions and causes of death (intermediate cause - description and basic cause - code); 9 showed regular completeness concerning the identification of the deceased (date of birth and age) on the V block (mother\'s age, type of pregnancy, mode of delivery, weight of the fetus / baby birth, death of the fetus / baby compared to delivery) and on the conditions and causes of death (direct cause code, basic cause description); 2 showed good completeness concerning the identification of the deceased (sex and race / color) and, finally, 2 showed excellent completeness concerning the place of occurrence of death (date of admission and date of death or the disappearance corpse). The SIS-ROH had coverage below 50% calculated on mortality data estimated by the National Survey of Causes of Death (INCAM). Some SIS-ROH variables and COS showed inconsistencies. There was a lack of agreement to direct cause between SIS-ROH and COs.

Orientador: Vera Lucia Pamplona Tonete / Resumo: Introdução: atualmente, embora se constate a redução dos índices de morbimortalidade infantil em todas as regiões do país, ainda há muito que se fazer para promover a saúde de crianças, especialmente daquelas mais vulneráveis. O presente estudo aborda o tema da vigilância à saúde de recém-nascidos de risco, com base em protocolo de organização de serviços. Considera-se que protocolo compõe-se de rotinas de cuidados e ações de gestão de um determinado serviço, equipe ou departamento, elaborado a partir da produção de conhecimentos e práticas dos profissionais envolvidos, com respaldo de evidências científicas. Objetivo: elaborar protocolo de organização de serviços para a redução de óbitos infantis na região de saúde do Vale do Jurumirim, São Paulo, com enfoque na vigilância à saúde de recém-nascidos de risco. Aspectos metodológicos: trata-se de uma pesquisa-intervenção, composta por uma etapa inicial, quando foi realizado estudo transversal e descritivo sobre o perfil epidemiológico regional de recém-nascidos vivos em 2013 e das crianças que foram a óbito nesse mesmo ano, durante o primeiro ano de vida, buscando a correspondência aos critérios de risco ao nascer indicados pelo Ministério da Saúde. Nesta primeira etapa, buscou-se também caracterizar a rede de atenção à saúde materno-infantil disponível na região em foco. Em uma etapa posterior, foi realizada intervenção participativa, que incluiu duas oficinas de oito horas para elaboração do protocolo pretendido, envolvendo 3... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: Although it is currently noticed a decline in infant mortality rate in all the regions of the country there is still a lot to do to promote child health care, especially those children who are more vulnerable. The current study deals with the topic of health monitoring of newborn babies at risk based on service organizing protocol. It is considered that protocol consists of routine care and management procedure of a particular service, team or department, by putting together healthcare professionals’ knowledge and experience and supported by scientific evidences. Objective: Putting together service organizing protocol to decline infant mortality in the region of Vale do Jurumirim, São Paulo, focused on health care monitoring of newborn babies at risk. Methodological Aspects: It is about intervention survey consisted of an initial stage when it was done a transversal and descriptive study of the regional epidemic profile of newborn babies born in 2013 and one-year-old children or younger who died that year, aiming at the correspondence between risk criteria at birth according to the Department of Health. In this initial stage, attention to maternal-infant health care was given when it was available in that region. In a later stage, participative intervention was carried out, which included two eight-hour workshops to put together intended protocol, involving 34 managers and healthcare professionals and maternal-infant health care monitoring of that particular reg... (Complete abstract click electronic access below) / Mestre