INTRODUÇÃO: A importância de se avaliar sistemas e serviços de saúde: aumento de gastos, avanços tecnológicos, envelhecimento da população, deficiências com as práticas na assistência, iniquidades na alocação de recursos, necessidade de prestação de contas aos órgãos controladores e à sociedade, melhorias e reformas no sistema e serviços de saúde. A avaliação de desempenho de serviços de saúde demonstra parte importante do desempenho do sistema de saúde, permitindo comparações de desempenho de processos e resultados, à medida que os serviços avaliados tenham articulações entre si, e que o desfecho tenha relações com todos os níveis da atenção avaliados. OBJETIVO: avaliar o desempenho dos serviços públicos de saúde de um município paulista de médio porte, no período de 2008 a 2015, quanto a resultados de qualidade nas dimensões do acesso, da efetividade e da adequação de serviços. MATERIAL E MÉTODO: estudo exploratório, com análise descritiva de dados quantitativos. Utilizados indicadores de saúde dos sistemas de informação do Ministério da Saúde, e populacionais do IBGE. Foram distribuídos nas dimensões do acesso, efetividade e adequação, conforme modelo do PROADESS - Metodologia de Avaliação do Desempenho do Sistema de Saúde; para a interpretação do desempenho foi realizada comparação entre o nível municipal e outros três níveis (estado de São Paulo, região Sudeste e Brasil). RESULTADOS: acesso: taxa de internação, cirurgia de revascularização, angioplastia e imunização por tetra/pentavalente demonstraram melhor desempenho dos serviços de saúde municipais em relação aos demais níveis; cobertura Estratégia Saúde da Família e vacinação do idoso contra a gripe demonstraram pior desempenho, porém com tendência de melhora ao longo do tempo. Adequação: consultas de pré-natal do município com melhor desempenho em relação aos demais níveis, e mais próximas do preconizado; histerectomia e partos cesáreos com pior desempenho. Efetividade: mortes em internações por infarto agudo do miocárdio com melhor desempenho para o município; internações por Condições Sensíveis à Atenção Básica, sífilis congênita em menor de um ano e amputação de membros inferiores em diabéticos com pior desempenho municipal em relação aos outros três níveis do estudo. CONCLUSÃO: quanto ao acesso, no conjunto dos indicadores o desempenho foi positivo, com melhor resultado para a atenção hospitalar em relação à atenção básica; quanto à adequação, o desempenho foi desfavorável ao município em comparação com os demais níveis, assim como na efetividade o desempenho municipal também foi inferior aos outros três níveis pesquisados, demonstrando fragilidade na atenção básica da assistência. / INTRODUCTION: The importance of evaluating health systems and services: increased expenditures, technological advances, aging of the population, deficiencies with assistance practices, iniquities in resource allocation, accountability to controlling organs and society, improvements and reforms in the health system and services. The performance evaluation of health services demonstrates an important part of the performance of the health system, allowing comparisons of performance of processes and results, as the services evaluated have articulations among them, and that the outcome has relations with all levels of attention evaluated. OBJECTIVE: to evaluate the performance of public health services in a medium-sized São Paulo municipality, from 2008 to 2015, in terms of quality, access, effectiveness and adequacy of services. MATERIAL AND METHOD: exploratory study, with descriptive analysis of quantitative data. Health indicators of the information systems of the Ministry of Health and of the IBGE population were used. They were distributed in the dimensions of access, effectiveness and adequacy, according to the model of the PROADESS - Methodology for Evaluation of Health System Performance; for the interpretation of the performance was carried out comparison between the municipal level and other three levels (state of São Paulo, Southeast region and Brazil). RESULTS: access: hospitalization rate, revascularization surgery, angioplasty and tetra / pentavalent immunization demonstrated better performance of the municipal health services in relation to the other levels; coverage Family Health Strategy and vaccination of the elderly against influenza showed worse performance, but with a tendency to improve over time. Adequacy: prenatal consultations of the municipality with better performance in relation to the other levels, and closer to that recommended; hysterectomy and cesarean delivery with worse performance. Effectiveness: deaths in hospitalizations due to acute myocardial infarction with better performance for the municipality; hospitalizations for conditions sensitive to primary care, congenital syphilis in less than one year and amputation of lower limbs in diabetics with worse municipal performance in relation to the other three levels of the study. CONCLUSION: with regard to access, in the set of indicators, performance was positive, with a better result for hospital care in relation to primary care; in terms of adequacy, the performance was unfavorable to the municipality in comparison to the other levels, as well as in the effectiveness, the municipal performance was also inferior to the other three levels surveyed, showing weakness in the basic assistance care.

Introdução: A energia elétrica e ultrasônica são utilizadas com freqüência na prostatectomia radical laparoscópica e podem lesar os nervos cavernosos adjacentes através da dissipação térmica. Em contrapartida, a energia laser tem potencial para proporcionar uma dissecção precisa, com boa hemostasia e pequena lesão dos tecidos adjacentes. Este estudo avalia o efeito do laser KTP na dissecção laparoscópica do feixe neuro-vascular cavernoso em modelo experimental canino. Material e Métodos: Um total de 36 cães foi dividido igualmente em três grupos. Realizou-se a dissecção unilateral do feixe neurovascular cavernoso utilizando (1) laser KTP (KTP), (2) bisturi ultrasônico (BU), e (3) tesoura e clipes metálicos (TC), mantendo o lado contralateral intacto. Realizou-se a análise do tempo operatório e sangramento em cada grupo, assim como a análise funcional, através do coeficiente entre a pressão intracavernosa e pressão arterial média (PIC/PAM) durante a estimulação do feixe neurovascular cavernoso. Metade dos animais de cada grupo foi mantida viva por 30 dias e submetidos à nova neuroestimulação. Foram avaliados ainda os efeitos da dissipação térmica através da análise termográfica em fragmentos de peritôneo parietal e a extensão histológica da necrose tecidual na fáscia prostática desde a superfície de corte de cada instrumento. Resultados: O tempo de dissecção do feixe neuro-vascular cavernoso foi similar entre os grupos (KTP vs. BU p=0.21, KTP vs. TC p=0.81, BU vs. TC p=0.22). A dissecção utilizando o BU resultou em um prejuízo significativo na resposta à neuroestimulação quando comparado aos grupos TC e KTP no experimento agudo (BU vs. KTP p<0.001, BU vs. TC p<0.001), e crônico (BU vs. KTP p=0.02, BU vs. TC p=0.02). A análise histológica demonstrou uma área de necrose desde a superfície de corte com a utilização do laser KTP de aproximadamente 500 um, enquanto que com o uso do BU essa área se extendeu em média por 2 mm. A avaliação termográfica mostrou uma dissipação térmica significativamente maior do BU comparado ao laser KTP (laser KTP 0.98 mm vs. BU 6.25 mm, p<0.0001). Conclusão: O uso do laser KTP na dissecção laparoscópica do feixe neuro-vascular cavernoso apresentou resultado funcional semelhante à técnica sem emprego de energia térmica utilizando tesoura e clipes, enquanto o bisturi ultrasônico foi associado a um prejuízo significativo na função dos nervos cavernosos. / Introduction: Electrical and ultrasonic energy used in nerve-sparing laparoscopic radical prostatectomy can compromise cavernous nerve function. Laser energy may potentially allow fine dissection with good hemostasis and minimal adjacent tissue injury. This study examines the electrophysiological, histological and thermal mapping features of KTP laser dissection on cavernous nerve function in the survival canine model. Materials and Methods: A total of 36 dogs were divided into 3 groups. Laparoscopic unilateral neurovascular bundle (NVB) mobilization was performed using either: (1) KTP laser (n=12), (2) ultrasonic shears (US) (n=12), or (3) athermally with cold scissors (AT) (n=12). The contralateral NVB remained undissected as an internal control. NVB function was assessed acutely in all dogs, and after 1-month survival in 50% of the dogs of each group. Peak intracavernosal pressure response to cavernous nerve stimulation was measured as a percentage of mean arterial pressure (ICP/MAP). Strips of peritoneum were sectioned ex-vivo with the KTP laser and US shears for thermographic mapping. Histological evaluation of prostatic fascia necrosis from the cutting surface was also performed. Results: Comparing KTP and AT groups, the erectile response to nerve stimulation was similar acutely and at 1 month (acute ICP/MAP: KTP 92%, AT 96% p=0.54; chronic ICP/MAP: KTP 95%, AT 98% p=0.71). In contrast, US dissection resulted in a significant decrease in the ICP response compared to the KTP and AT groups (acute ICP/MAP: US 49%, KTP 92%, AT 96%. US vs. KTP p<0.001, US vs. AT p<0.001; chronic ICP/MAP: US 58%, KTP 95%, AT 98%, US vs. KTP p=0.02, US vs. AT p=0.02). Mean NVB dissection times were similar (KTP 27.5min, US 19.9min, AT 26.6min, KTP vs. US p=0.21, KTP vs. AT p=0.81, US vs. AT p=0.22). Histopathology demonstrated an acute zone of laser-induced necrosis of approximately 500 um compared to 2 mm with US dissection. Thermographic assessment demonstrated significantly less collateral thermal spread from the KTP laser compared to US (mean thermal spread >60 oC KTP 0.98 mm vs. US 6.25 mm, p<0.0001). Conclusions: Use of KTP laser for NVB mobilization preserved cavernous nerve function comparable to standard athermal techniques using cold scissors and was superior to ultrasonic shears.

Introdução: A energia elétrica e ultrasônica são utilizadas com freqüência na prostatectomia radical laparoscópica e podem lesar os nervos cavernosos adjacentes através da dissipação térmica. Em contrapartida, a energia laser tem potencial para proporcionar uma dissecção precisa, com boa hemostasia e pequena lesão dos tecidos adjacentes. Este estudo avalia o efeito do laser KTP na dissecção laparoscópica do feixe neuro-vascular cavernoso em modelo experimental canino. Material e Métodos: Um total de 36 cães foi dividido igualmente em três grupos. Realizou-se a dissecção unilateral do feixe neurovascular cavernoso utilizando (1) laser KTP (KTP), (2) bisturi ultrasônico (BU), e (3) tesoura e clipes metálicos (TC), mantendo o lado contralateral intacto. Realizou-se a análise do tempo operatório e sangramento em cada grupo, assim como a análise funcional, através do coeficiente entre a pressão intracavernosa e pressão arterial média (PIC/PAM) durante a estimulação do feixe neurovascular cavernoso. Metade dos animais de cada grupo foi mantida viva por 30 dias e submetidos à nova neuroestimulação. Foram avaliados ainda os efeitos da dissipação térmica através da análise termográfica em fragmentos de peritôneo parietal e a extensão histológica da necrose tecidual na fáscia prostática desde a superfície de corte de cada instrumento. Resultados: O tempo de dissecção do feixe neuro-vascular cavernoso foi similar entre os grupos (KTP vs. BU p=0.21, KTP vs. TC p=0.81, BU vs. TC p=0.22). A dissecção utilizando o BU resultou em um prejuízo significativo na resposta à neuroestimulação quando comparado aos grupos TC e KTP no experimento agudo (BU vs. KTP p<0.001, BU vs. TC p<0.001), e crônico (BU vs. KTP p=0.02, BU vs. TC p=0.02). A análise histológica demonstrou uma área de necrose desde a superfície de corte com a utilização do laser KTP de aproximadamente 500 um, enquanto que com o uso do BU essa área se extendeu em média por 2 mm. A avaliação termográfica mostrou uma dissipação térmica significativamente maior do BU comparado ao laser KTP (laser KTP 0.98 mm vs. BU 6.25 mm, p<0.0001). Conclusão: O uso do laser KTP na dissecção laparoscópica do feixe neuro-vascular cavernoso apresentou resultado funcional semelhante à técnica sem emprego de energia térmica utilizando tesoura e clipes, enquanto o bisturi ultrasônico foi associado a um prejuízo significativo na função dos nervos cavernosos. / Introduction: Electrical and ultrasonic energy used in nerve-sparing laparoscopic radical prostatectomy can compromise cavernous nerve function. Laser energy may potentially allow fine dissection with good hemostasis and minimal adjacent tissue injury. This study examines the electrophysiological, histological and thermal mapping features of KTP laser dissection on cavernous nerve function in the survival canine model. Materials and Methods: A total of 36 dogs were divided into 3 groups. Laparoscopic unilateral neurovascular bundle (NVB) mobilization was performed using either: (1) KTP laser (n=12), (2) ultrasonic shears (US) (n=12), or (3) athermally with cold scissors (AT) (n=12). The contralateral NVB remained undissected as an internal control. NVB function was assessed acutely in all dogs, and after 1-month survival in 50% of the dogs of each group. Peak intracavernosal pressure response to cavernous nerve stimulation was measured as a percentage of mean arterial pressure (ICP/MAP). Strips of peritoneum were sectioned ex-vivo with the KTP laser and US shears for thermographic mapping. Histological evaluation of prostatic fascia necrosis from the cutting surface was also performed. Results: Comparing KTP and AT groups, the erectile response to nerve stimulation was similar acutely and at 1 month (acute ICP/MAP: KTP 92%, AT 96% p=0.54; chronic ICP/MAP: KTP 95%, AT 98% p=0.71). In contrast, US dissection resulted in a significant decrease in the ICP response compared to the KTP and AT groups (acute ICP/MAP: US 49%, KTP 92%, AT 96%. US vs. KTP p<0.001, US vs. AT p<0.001; chronic ICP/MAP: US 58%, KTP 95%, AT 98%, US vs. KTP p=0.02, US vs. AT p=0.02). Mean NVB dissection times were similar (KTP 27.5min, US 19.9min, AT 26.6min, KTP vs. US p=0.21, KTP vs. AT p=0.81, US vs. AT p=0.22). Histopathology demonstrated an acute zone of laser-induced necrosis of approximately 500 um compared to 2 mm with US dissection. Thermographic assessment demonstrated significantly less collateral thermal spread from the KTP laser compared to US (mean thermal spread >60 oC KTP 0.98 mm vs. US 6.25 mm, p<0.0001). Conclusions: Use of KTP laser for NVB mobilization preserved cavernous nerve function comparable to standard athermal techniques using cold scissors and was superior to ultrasonic shears.

Adams et al. was the first to demonstrate an association between improved outcomes and provider experience in a 1973 study examining complication rates from coronary arteriograms.[1] In this study, a questionnaire was mailed to the directors of coronary arteriography laboratories throughout the US. They found that mortality was eight times higher in institutions performing fewer than 200 examinations per two-year period compared to institutions performing more than 800 examinations per two-year period. It was not until 1979, however, that efforts to systematically study outcomes in surgery were made by Luft and colleagues.[2] They demonstrated lower mortality rates at high-volume centers compared with low-volume centers for several high risk procedures, such as coronary artery bypass graft surgery (CABG) and vascular surgery. This landmark study set the stage for outcomes research in surgery. Over the past decade, additional studies have continued to show higher surgeon or hospital volumes to be associated with improved patient outcomes. [3-13] To what degree surgeon versus hospital volume each contribute to outcomes is controversial and depends on the procedure examined. Nevertheless, formal recommendations encouraging certain high-risk procedures be performed at high-volume hospitals began as early as 2000 by the Leapfrog group and other policy initiatives.[14, 15] Formal recommendations for surgeon volume, on the other hand, have been lacking. There has been mounting evidence, particularly in the last decade, that surgeon volume is associated with improved patient outcomes, independent of hospital volume. To what measure these data have influenced referral patterns from low- to high-volume surgeons is unknown.

Thesis (MHSc--Health Science) -- AUT University, 2009. / Includes bibliographical references. Also held in print (1 v. ; 30 cm.) in the Archive at the City Campus (T 617.103 FAD)

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2009. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2010.

Thesis (Ph. D.)--Rand Graduate School, 2002. / Title from web page (viewed Aug. 27, 2003). Includes bibliographical references.

A variety of programmes of health education are designed, addressing promotion of health of the Libyan community. These programmes employ various communication methods and use different education media. This research is the first to evaluate the national programmes of health education in Libya and to determine future needs. It compares health officials' assessments with those of the general public; providers and users. It also examines the health professionals' perceptions on their role in health education. Five questionnaires are used in this research. The first two questionnaires are designed for the evaluation purpose. The third and fourth questionnaires are to determine future needs. The fifth questionnaire is about health professionals' role in health education. Both of the groups, the officials and the general public, assessed TV as being the most effective health education medium. The general public favoured the 'spots' over regular programmes. Their assessment of the radio effectiveness was much lower. Officials, on the other hand, favoured regular programmes over 'spots', and placed radio's role only slightly lower than the impact of TV. Both of the groups recommended wide use of TV for future health education. Children and youth are considered the main groups to be targeted with respect to most of health issues. School is the most preferred setting to target the children. Youth and sport clubs are recommended in communicating with the youth. Assessment of future priority health issues attracted different responses from the two groups. Health professionals perceive that they are responsible for mediating health education and consider this role as important. However, effectiveness of the existing role of health professionals in health education in Libya is evaluated differently. Main barriers to an effective role are identified and required solutions are suggested. The findings of this research suggest the need for systematic consultation across professional and lay groups as a requisite preliminary for statutory health education/promotion initiatives. These findings also address the need for further work and research in certain areas.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.