Vårdprogram för höftfraktur har tidigare använts vid Akademiska sjukhuset i Uppsala.  Höftspår är en ny process och målet är att underlätta flödet genom hela vårdkedjan. Syfte: Syftet är att studera hur Höftspår har påverkat omvårdnaden inom områdena; smärtskattning, smärtbehandling, vårdtid, förekomst av hudinspektion samt förekomst av trycksår hos patienter med höftfraktur, i jämförelse med Vårdprogram för höftfraktur. Metod: Journalgranskning utfördes med en retrospektiv, deskriptiv och komparativ design. Urvalet utgjordes av 30 patientjournaler i grupp I, före införandet av Höftspår, och 30 patientjournaler i grupp II, från införandestart för Höftspår. Inkluderade patientjournaler var diagnosgrupp höftfraktur, >60 år, ankomst till akutmottagning med ambulans, bedömas av läkare som operationsfall med inläggning på samma sjukhus. Av de 30 granskade patientjournalerna i grupp II var inklusionskriteriet även fascia-iliaca blockad. Resultat: Resultat som framkom var kortare vårdtid på akutmottagning och en minskning i administrerad opiat. En förbättrad dokumentation av hudinspektion och smärtskattning sågs på akutmottagningen. Prehospitalt mättes ingen större skillnad i antal milligram administrerad opiat. På vårdavdelning minskade vårdtiden något och smärtskattning gjordes sällan. Hudinspektion utfördes överlag ofta på vårdavdelning men minskade något efter införandet av Höftspår. Slutsats: Vi ser en kvalitetshöjning för patienten med höftfraktur, i och med kortare vårdtider och bättre smärtbehandling. / Care-programmes for hip-fracture were previously employed at Akademiska hospital in Uppsala. Hip-track is a new process and the objective is to facilitate the flow through the entire chain of care. Objective: The aim of this study was to investigate how the care-programme Hip-track has affected nursing within the areas: pain-assessment, pain-treatment, care-time, skin-inspection and pressure-ulcer of patients with hip-fracture compared with previous care-program. Method: A review of health-records was carried out with a retrospective, descriptive and comparative design. The sample consisted of 30 health-records, before the introduction and 30 health-records after the introduction of Hip-track. Included health-records: diagnosis-group hip-fracture, > 60 years of age, arrival to the emergency-departement with ambulance, assessed by doctors as a surgical-case and admitted to the hospital. After the introduction was fascia-iliaca-block a criteria for inclusion.  Results: The results that emerged were shorter care-time at the emergency-department and a reduction in administered opioid. Improved documentation of skin-inspection and  pain-assessment were seen at the emergency-departement. In prehospital-care, there were no notable differences observed of opioid administered. Care-time decreased at the ward and pain-assessment. Skin-inspection was in general often done but decreased with introduction of Höftspår. Conclusion: Hip-track is quality-improvement, shorter care time and better pain-treatment.

Hip fracture has long been considered as the most serious consequence of osteoporosis, which includes chronic pain, disability, and even death. In the elderly population, a femur fracture is very common. It is assessed that 50% of women aged 50 or older may experience a hip fracture in their remaining life. Hip fracture is among the most common injuries and can lead to substantial morbidity and mortality. In the US alone, over 250,000 hip fractures occur each year and this number is expected to double by the year 2040. Statistics indicate that over 20% of people who experience a hip fracture die within one year and only 25% have a total recovery. Femur fractures are now becoming a major social and economic burden on the health care system. In practice, it is very difficult to predict the femur fracture risks. One of the main reasons is that there is not a robust and easy-to-get measure to quantify the strength of the bone. Clinicians use bone mineral density (BMD) as an indicator of osteoporosis and fracture risk. Several studies showed that BMD cannot be used alone to identify bone strength. In fact, the majority of patients who suffer from fractures have normal or even higher BMD scores. There are a large number of risk factors that contribute to the occurrence of femur fracture, which should also be involved in predicting hip fracture risks. For example, age, weight, height, ethnicity and so on. Some of the factors might not have been identified yet. Thus, there will be a high level of uncertainty in the clinical dataset, which makes it difficult to construct and validate a hip risk prediction model. The objective of the dissertation is to construct an improved hip fracture risk prediction model. Due to the difficulty of obtaining experimental or clinical data, computational simulations might help increase the predictive ability of the risk model. In this research, the hip fracture risk model is based on a support vector machine (SVM) trained using a clinical dataset from the Women's Health Initiative (WHI). In order to improve the SVM-based hip fracture risk model, data from a fully parameterized finite element (FE) model is used to supplement the clinical dataset. This FE model allows one to simulate a wide range of geometries and material properties in the hip region, and provides a measure of risk based on mechanical quantities (e.g., strain). This dissertation presents new approaches to fuse the clinical data with the FE data in order to improve the predictive capability of the hip fracture risk prediction model. Two approaches are introduced in this dissertation to construct a hybrid risk model: an "augmented space" approach and a "computational patients" approach. This work has led to the construction of a new online hip fracture risk calculator with free access.

Prostate cancer is frequently diagnosed in elderly men and, despite the largely unproven survival benefits of treatment, the majority receive treatment. Treatment options include surgery, radiation, and/or androgen deprivation therapy (ADT). Risks associated with treatment include hip fracture. Current understanding suggests that hip fracture is a frequent cause of morbidity and mortality in the elderly, and both radiation treatment and ADT can increase the risk of hip fracture. It is important to understand these risks so they can be minimized and the morbidity of treatment reduced. The objectives of this study were to estimate the risk of hip fracture as a major adverse outcome of treatment for prostate cancer among elderly men. The specific objectives include estimating: 1) the risk of hip fracture and the dose-risk relationship among patients receiving curative radiation treatment, and 2) the risk of hip fracture associated with palliative ADT and relapsed ADT compared to curative ADT. The cancer diagnosis and treatment records of 32,673 men were linked to their hospital discharge abstracts. The risk of hip fracture was estimated using Cox regression and the estimates were adjusted for age, comorbidity, income, and year of diagnosis. The risk of hip fracture was 59% higher among men who received curative radiation when compared to men who received curative surgery. The risk of hip fracture fell by 6% with each one Gy increase in radiation dose between 55 and 81 Gy Biological Equivalent Dose to the hip-bone. The risk of hip fracture for subjects in the palliative ADT and relapsed ADT categories was 5.98 and 5.77 times the risk in comparison to men who received curative ADT treatment. Curative radiation treatment is associated with an increased risk of hip fracture when compared to curative surgery. The risk of hip fracture is greater with ADT for palliation and relapsed cancer than with curative treatment. Current treatments for prostate cancer contain significant risk of hip fracture for elderly men and these risks should be considered as part of the treatment decision.

Hip fracture has been identified as one of the main health problems in the elderly. To improve the accuracy in assessing subject-specific hip fracture risk, this study proposed normalized cortical bone thickness (NCBT) estimated from patient’s hip DXA as an alternative predictor of hip fracture risk. Hip fracture risk index (HFRI) derived from DXA-based finite element model was utilized as a baseline for evaluating the effectiveness of NCBT in predicting hip fracture risk. It was found that NCBT at the lateral side of the narrowest femoral neck had the strongest correlation with femoral neck HFRI among the six locations of the proximal femur. This study suggests that it is possible to use NCBT as a surrogate for a quick evaluation of hip fracture risk. Yet its clinical performances such as sensitivity to therapy effectiveness and the ability to discriminate clinical fracture cases will be investigated in a future study.

The overall aim of the thesis was to investigate whether patient safety can be improved for patients with hip fracture by nutritional intervention and by pharmacological treatment with cranberry concentrate. Another aim was to describe the patients’ experience of involvement in their care. The thesis includes results from four studies that include both quantitative and qualitative design. Studies I and II were intervention studies with a quasi-experimental design, with intervention and comparison groups. Study III was a randomised, double-blind, placebo-controlled trial with intervention and control groups. Study IV took a qualitative approach. Study I showed that when patients with hip fracture received nutritional supplementation according to nutritional guidelines, from admission until five days postoperatively, fewer patients developed pressure ulcers. Study II showed that it is possible to objectively evaluate a short-term nutritional intervention through the nutritional biochemical marker IGF-1, as it was affected by a five-day high-energy regimen. The randomised controlled trial, Study III, showed that a short-term treatment from admission until five days postoperatively with cranberry as capsules does not seem to be useful in preventing positive urine cultures in female patients with hip fracture and a urinary catheter. Finally, Study IV showed that patients with hip fracture reported experiencing very little involvement in their nursing care, to the extent that fundamental aspects of nursing care went unfulfilled. Patients did not feel valued by the nurses and unbearable pain that affected rehabilitation was reported. Positive interactions with nurses, however, did encourage patients to be more active. It is possible for every nurse to improve patient safety at bedside when caring for patients with hip fracture. Simply by increasing caloric/energy intake, it is possible to prevent pressure ulcers. It is also important to involve patients in nursing care, since the patients have experienced low or almost no involvement in care. Nurses need to see each patient as a whole person with different wishes and needs. However, certain prerequisites have to be in place to give nurses the opportunity to increase patient safety at bedside for patients with hip fracture.

Introduction Patients with femoral neck fractures (FNFs) constitute an increasing health care problem which affect patient’s daily living after the trauma, reduce self-care possibilities, and increases mortality. Treatment of these patients is associated with increasing costs. Prospective systematic audit and national registers have been suggested as one of the best approaches to measuring and improving outcomes. Previously neither detailed audit of patients with hip fracture nor further analysis of data was conducted in Lithuania Aim of the research project – to estimate factors affecting outcome in patients with FNF and to audit patients’ care, assessing importance to the outcome results, comparing FNF patients treated in Lithuania and Sweden. Tasks of the research project: 1. To identify factors affecting functional outcome and quality of life in femoral neck fracture patients at four months follow-up. 2. To estimate the changes in functional outcome and quality of life in fe-moral neck fracture patients at four months and at one year follow-up. 3. To compare hip fracture patients care in Kaunas Clinics and Lund University Hospital and identify differences during patients’ trans¬por-tation, preoperative, and postoperative time periods. 4. To compare functional and quality of life outcome in femoral neck fracture patients treated in Kaunas Clinics and Lund University Hos-pital. Patients and methods To achieve the aims of the research project, three consequential stu¬dies... [to full text] / Šlaunikaulio kaklo (ŠK) lūžis - trauma, stipriai įtakojanti ir pakeičianti kiekvieno paciento tolimesnį gyvenimą, kadangi mažina savarankiškumą, skatina negalią po lūžio, didina mirštamumo riziką. Šiuolaikinei sveikatos priežiūros sistemai tai didelis ekonominis iššūkis, susijęs su pacientų gydymu, reabilitacija, priežiūra bei poreikiais pirmaisiais metais po lūžio Tyrimo tikslas – nustatyti veiksnius, turinčius įtakos šlaunikaulio kaklo lūžius patyrusių pacientų gydymo rezultatams, įvertinant pacientų priežiūrą iki patekimo į gydymo įstaigą ir hospitalizacijos laikotarpiais, lyginant rezultatus su Lundo universitetine ligonine. Tyrimo uždaviniai: 1. Įvertinti veiksnius, turinčius įtakos pacientų, patyrusių šlaunikaulio kaklo lūžius, klubo sąnario funkcijai bei su sveikata susijusiai gyvenimo kokybei praėjus keturiems mėnesiams po traumos. 2. Nustatyti klubo sąnario funkcijos ir su sveikata susijusios gyvenimo kokybės pokyčius nuo keturių mėnesių iki vienerių metų po traumos. 3. Palyginti šlaunikaulio lūžius patyrusių pacientų priežiūrą Kauno klinikose ir Lundo universitetinėje ligoninėje, įvertinant skirtumus pacientų transportavimo į gydymo įstaigą, priešoperaciniu ir pooperaciniu laikotarpiais. 4. Palyginti klubo sąnario funkciją ir su sveikata susijusią gyvenimo kokybę tarp pacientų, gydytų Kauno klinikose ir Lundo universitetinėje ligoninėje, praėjus keturiems mėnesiams po traumos. Tyrimo metodika Tyrimas vykdytas Lietuvos Sveikatos mokslų universiteto Kauno... [toliau žr. visą tekstą]

Fall-related hip fractures are a substantial public health issue. Unfortunately, little is known about whether the effective stiffness of the pelvis, a critical component governing impact force during lateral falls, differs substantially across different segments of the population. The objective of this thesis was to enhance the knowledge base surrounding pelvis impact dynamics by assessing the influence of gender and body mass index (BMI) on the effective stiffness of the pelvis, and on resulting peak loads applied to the hip, during sideways falls. Towards this end I conducted pelvis release trials (in which the pelvis was suspended and suddenly released onto a force plate) with males and females with low (<22) and high (>28) BMIs. One resonance-based (kvibe), and three force-deflection based (k1st, kcombo 300, and kcombo opt) methods of effective pelvic stiffness estimation were examined. The resulting stiffness estimates, and peak forces sustained during the pelvis release experiments, were compared between each BMI and sex group. The optimized force-deflection stiffness estimation method, kcombo opt provided the strongest fit to the experimental data. Strong main effects of BMI (f (1,13) = 10.87, p = 0.003) and sex (f (1,13) = 5.97, p = 0.022) were found for this stiffness estimation method. Additionally, a significant BMI-sex interaction was observed (f (3,6) = 5.31, p = 0.030), with low BMI males having much higher stiffness estimates than any other group. Normalized peak forces were higher in low BMI participants than in high BMI participants (f(1,13)=24.9, p<0.001). Linear regression demonstrated that peak impact force was positively associated with effective pelvic stiffness (β = 0.550, t(25) = 3.110, p=0.005), height (β = 0.326, t(25) = 2.119, p=0.045) and soft tissue thickness (β = 0.785, t(25) = 4.573, p<0.001). This thesis has demonstrated that body habitus and sex have significant effects on the stiffness of the pelvis during lateral falls. These differences are likely related to a combination of soft tissue and pelvic anatomical differences between BMI and sex groups. Pelvic stiffness, along with other easily collected variables, may be helpful in predicting peak forces resulting from lateral falls in the elderly. Differences in pelvic stiffness estimates between BMI and sex groups, and estimation method, necessitate careful consideration. These data will aid in selecting the most appropriate pelvic stiffness parameters when modeling impact dynamics for higher energy falls.

Prostate cancer is frequently diagnosed in elderly men and, despite the largely unproven survival benefits of treatment, the majority receive treatment. Treatment options include surgery, radiation, and/or androgen deprivation therapy (ADT). Risks associated with treatment include hip fracture. Current understanding suggests that hip fracture is a frequent cause of morbidity and mortality in the elderly, and both radiation treatment and ADT can increase the risk of hip fracture. It is important to understand these risks so they can be minimized and the morbidity of treatment reduced. The objectives of this study were to estimate the risk of hip fracture as a major adverse outcome of treatment for prostate cancer among elderly men. The specific objectives include estimating: 1) the risk of hip fracture and the dose-risk relationship among patients receiving curative radiation treatment, and 2) the risk of hip fracture associated with palliative ADT and relapsed ADT compared to curative ADT. The cancer diagnosis and treatment records of 32,673 men were linked to their hospital discharge abstracts. The risk of hip fracture was estimated using Cox regression and the estimates were adjusted for age, comorbidity, income, and year of diagnosis. The risk of hip fracture was 59% higher among men who received curative radiation when compared to men who received curative surgery. The risk of hip fracture fell by 6% with each one Gy increase in radiation dose between 55 and 81 Gy Biological Equivalent Dose to the hip-bone. The risk of hip fracture for subjects in the palliative ADT and relapsed ADT categories was 5.98 and 5.77 times the risk in comparison to men who received curative ADT treatment. Curative radiation treatment is associated with an increased risk of hip fracture when compared to curative surgery. The risk of hip fracture is greater with ADT for palliation and relapsed cancer than with curative treatment. Current treatments for prostate cancer contain significant risk of hip fracture for elderly men and these risks should be considered as part of the treatment decision.

Fraturas de quadril e fêmur são um problema de saúde pública emergente, associado a um elevado índice de mortalidade e morbidade em todo mundo, com alto impacto na qualidade de vida dos pacientes. A Úlcera por Pressão (UP) é uma complicação que pode interferir para aumento destes índices. O estudo teve como objetivos identificar e caracterizar os pacientes que sofreram fratura de quadril e fêmur atendidos em um Hospital Universitário do interior Paulista; verificar a incidência e prevalência da UP e descrever a evolução das lesões até a alta; relacionar a presença de UP com as variáveis clinicas, incluindo o risco para UP por meio da Escala de Braden e o grau de independência para as Atividades de Vida Diária (AVD) pelo Índice de Katz; e analisar o valor preditivo dos escores da escala de Braden para esta população. Após aprovação pelo Comitê de Ética, foram incluídos na amostra 30 pacientes que aceitaram participar. Os dados foram coletados na admissão, no 1º dia pós-operatório ou no 5º dia de internação e na alta. Os participantes eram predominantemente do sexo feminino (53,3%), brancos (76,7%), acima dos 60 anos de idade (56,7%), alfabetizados (60%) e aposentados (33,3%). O local anatômico mais comum da fratura foi o colo do fêmur. A comorbidade mais comum foi do Sistema Cardiocirculatório (53,3%). O tempo médio entre a admissão e a cirurgia foi de 2,92 dias. O tempo total de cirurgia variou entre 2 a 4 horas. O tempo médio de internação foi 14,20 dias. A complicação mais comum no pós-operatório foi a confusão e agitação (66,7%). Em relação à independência funcional para as AVD, 50% eram totalmente dependentes na primeira e segunda avaliação e 40% no momento da alta. Quanto ao risco para UP, o escore médio da Escala de Braden na admissão foi 12,66 (DP: 2,52), no segundo momento 13,73 (DP: 3,10) e na Alta 15,03 (DP: 3,83). Para os pacientes que tiveram UP durante a internação os escores foram menores em todos os momentos (p\"0,05). A prevalência de UP foi de 33,3% e a incidência 26,6%. No momento da Alta, dos 10 casos considerados no estudo de prevalência, 9 ainda apresentavam UP. Na análise dos resultados pela regressão logística identificou-se que das covariáveis sócio-demográficas e clínicas investigadas apenas o escore da escala de Braden explicava a ocorrência da UP (p\"0,05). A análise do valor preditivo dos escores da escala de Braden pelo Teste de Fisher identificou que quanto menor a pontuação na escala, maior a quantidade de pacientes com UP no segundo e terceiro momentos (p\"0,05). / Fractures of hip and femur are an emerging public health problem, associated with a high rate of mortality and morbidity worldwide, with a high impact on the quality of life of patients. The Pressure Ulcer by (PU) is a complication that can interfere to increase these rates. The study aimed to identify and characterize the patients who suffered from hip and femur fracture treated in a University Hospital from inside Paulista; check the incidence and prevalence of UP and describe the evolution of the injury until discharge; relate the presence of the UP clinical variables, including the risk to UP by Scale of Braden and the degree of independence for the Activities of Daily Living (AVD) by Katz Index, and examine the predictive value of the scores of the scale of Braden for this population. After approval by the Ethics Committee, were included in the sample 30 patients who agreed to participate. Data were collected at admission, at 1 postoperative day or on the 5th day of hospitalization and discharge. Participants were predominantly female (53.3%), white (76.7%), over 60 years of age (56.7%), literacy (60%) and retirees (33.3%). The most common anatomical location of the fracture was the lap of the femur The most common comorbidity was System Cardiac (53.3%). The average time between admission and surgery was 2.92 days. The total time of surgery ranged from 2 to 4 hours. The average length of stay was 14.20 days. The most common complication in the postoperative period was the confusion and agitation (66.7%). Regarding the functional independence for the AVD, 50% were totally dependent on the first and second evaluation, and 40% at the time of discharge. The likelihood for UP, the scoring average of Braden Scale at admission was 12,66 (SD: 2,52), the second time 13,73 (SD: 3,10) and the High 15.03 (SD: 3,83). For patients who had UP during hospitalization the scores were lower at all times (p 0.05). The prevalence of UP was 33.3% and 26.6% incidence. At the time of Discharge, of the 10 cases considered in the study of prevalence, 9 still had UP. In the analysis of the results by logistic regression identified that the covariates socio-demographic and clinical investigated only the score of the scale of Braden explained the occurrence of UP (p 0.05). The analysis of the predictive value of the scores of the scale of the test Braden Fisher identified that the lower the score on the scale, the greater the number of patients with UP in the second and third times (p 0.05).

Orientador: Djalma de Carvalho Moreira Filho / Tese (doutorado) - Universidade Estadual de Campinas. Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-16T10:58:46Z (GMT). No. of bitstreams: 1 Vidal_EdisonIglesiasdeOliveira_D.pdf: 5523772 bytes, checksum: 95d09fb9d160d1f4bfcc3cfe1b5a30d9 (MD5) Previous issue date: 2010 / Resumo: As fraturas do fêmur proximal (FFP) correspondem a um importante problema de saúde pública em todo o mundo. Dentre todas as fraturas associadas à osteoporose são consideradas como as mais graves e correlacionam-se com os maiores índices de morbimortalidade, dependência funcional e custos para os indivíduos e os sistemas de saúde. O maior crescimento em sua incidência nos próximos anos é esperado nos países em desenvolvimento, todavia, estes também são os locais onde é maior a carência por dados acerca da epidemiologia dos pacientes acometidos por estas fraturas. A presente pesquisa teve como objetivo analisar alguns aspectos desta epidemiologia tanto no âmbito nacional como internacional. Como resultado foram confeccionados três artigos abordando esta temática. O primeiro artigo avaliou, a partir de uma base de dados de todas as hospitalizações por FFP na província de Quebec, no Canadá, a hipótese da equivalência do intervalo de tempo entre a fratura e a cirurgia e o intervalo entre a hospitalização e a cirurgia, enquanto preditores da ocorrência de óbito intra-hospitalar. Após controle para a presença de outras variáveis, nenhum dos intervalos mostrou associar-se com a mortalidade intra-hospitalar. Concluiu-se que, ao menos na medida em que a diferença entre os intervalos sejam pequenas como no caso observado, os mesmos podem ser utilizados de modo intercambiável sem comprometer a interpretação da associação entre o timing cirúrgico e a mortalidade intra-hospitalar, tal como pressuposto em diversos estudos prévios da literatura internacional. O segundo artigo buscou caracterizar o perfil clínico de idosos brasileiros hospitalizados em função de uma FFP, bem como os padrões de tratamento adotados, as complicações intra-hospitalares e a mortalidade ao longo de um ano. Dentre outros resultados de interesse, observou-se uma taxa de mortalidade em um ano de 13,4% (IC95%: 10,1 - 17,5%) e intervalos bastante elevados tanto entre a fratura e a hospitalização (média de 3,6 dias) como entre a internação e a cirurgia (média de 12,8 dias). O terceiro artigo procurou avaliar dentro do contexto brasileiro a associação entre o intervalo de tempo da fratura à cirurgia e a sobrevida dos idosos acomeditos por uma FFP. Após ajuste para variáveis de confundimento observou-se uma associação entre uma maior demora para a internação hospitalar e o óbito (HR: 1,08 , IC95%: 1,04 - 1,12, P < 0,001). Discute-se a questão das FFP enquanto objeto epidemiológico privilegiado, inclusive como um possível evento sentinela a ser monitorado no âmbito da saúde do idoso tanto no plano nacional como internacional. / Abstract: Hip Fractures (HF) represent the most severe of all osteoporotic fractures and remain an important cause of mortality, morbidity, dependency and costs for older adults and healthcare systems worldwide. Even though the greatest increase regarding the incidence of HF is expected to occur in the developing countries of the World, those are also the regions from where less information is available regarding the epidemiology of those fractures. The present research aimed to analyze selected aspects of the epidemiology of those fractures both in Brazil and internationally. Three manuscripts were produced as a direct result of this investigation. The first manuscript assessed the widely adopted assumption of interchangeability between the gap from hospital admission to surgical HF repair and the actual gap from fracture to surgery as predictors of in-hospital mortality among HF patients. A database encompassing all HF hospital admissions in Quebec, Canada, was the primary source of data for the analyses undertaken in this study. After statistical adjustment for the presence of other covariates neither of the time intervals to surgery was a significant predictor of in hospital mortality. As a conclusion, at least to the extent of the small differences observed between both gaps, they might be used interchangeably without compromising the interpretation of the relationship between surgical timing and in-hospital mortality, as assumed by previous studies. The second manuscript aimed to describe the clinical profile, treatment patterns, in hospital complications and one-year mortality of elderly Brazilians with an incident HF. Among other findings 13.4% (95%CI: 10.1% - 17.5%) of patients died during the first year and large gaps from fracture to hospital admission (mean 3.6 days) and from hospital admission to surgery (mean 12.8 days) were noted. The third manuscript examined in the context of a developing country the association between surgical timing and the survival of older adults after a HF. After adjusting for the presence of other covariates a small association between delayed hospital admission and reduced survival (HR: 1.08, 95% CI: 1.04 - 1.12) was observed. The point is made that HF should be considered a privileged epidemiological object, which might be used strategically as a sentinel event to be monitored both locally and internationally as a marker of the quality of health care to the elderly. / Doutorado / Epidemiologia / Doutor em Saude Coletiva