Reasons for encounter in primary health care in Brazil

[A conceptual framework for good preventive practices (or for quaternary prevention)]

Prevention is universally advocated, especially in the case of noncommunicable diseases. However, given the proliferation of preventive technologies, it does not seem defensible to generically encourage preventive behaviors and tests for healthcare professionals and users. In this essay, we articulate concepts, ideas and criteria for considering preventive measures, providing a minimum guide to be used by professionals (especially in primary healthcare) and managers. The concepts of primary, secondary and quaternary prevention are explored, as well as those of reductive and additive prevention, high-risk and population-based preventive strategies; evidence-based medicine and its contemporary crisis; the precautionary principle; health promotion, an expanded, person-centered approach and shared decision-making. This discussion was designed to improve competence in the evaluation of preventive measures, making clinical and health decisions more judicious and less iatrogenic regarding primary and secondary prevention.

Saxon Epidemiological Study in General Practice-6 (SESAM-6): protocol of a cross-sectional study

INTRODUCTION

General practitioners (GPs) are mostly the first point of contact for patients with health problems in Germany. There is only a limited epidemiological overview data that describe the GP consultation hours based on other than billing data. Therefore, the aim of Saxon Epidemiological Study in General Practice-6 (SESAM-6) is to examine the frequency of reasons for encounter, prevalence of long-term diagnosed diseases and diagnostic and therapeutic decisions in general practice. This knowledge is fundamental to identify the healthcare needs and to develop strategies to improve the GP care. The results of the study will be incorporated into the undergraduate, postgraduate and continuing medical education for GP.

METHODS AND ANALYSIS

This cross-sectional study SESAM-6 is conducted in general practices in the state of Saxony, Germany. The study design is based on previous SESAM studies. Participating physicians are assigned to 1 week per quarter (over a survey period of 12 months) in which every fifth doctor-patient contact is recorded for one-half of the day (morning or afternoon). To facilitate valid statements, a minimum of 50 GP is required to document a total of at least 2500 doctor-patient contacts. Univariable, multivariable and subgroup analyses as well as comparisons to the previous SESAM data sets will be conducted.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Technical University of Dresden in March 2023 (SR-EK-7502023). Participation in the study is voluntary and will not be remunerated. The study results will be published in peer-reviewed scientific journals, preferably with open access. They will also be disseminated at scientific and public symposia, congresses and conferences. A final report will be published to summarise the central results and provided to all study participants and the public.

Performance assessment of primary health care facilities in Brazil: Concordance between web-based questionnaire and in-person interviews with health personnel

This study is a concordance analysis comparing answers to two external assessment tools for Primary Health Care (PHC) facilities that use two different data collection methodologies: (a) external assessment through structured interviews and direct observation of facilities conducted by the National Program for Improvement of Access and Quality of Primary Care (AE-PMAQ-AB), and (b) a computerized web-based self-administered questionnaire for Assessment of the Quality of Primary Health Care Services (QualiAB). The two surveys were answered by 1,898 facilities located in 437 municipalities in the state of São Paulo, Brazil, between 2017 and 2018. Both surveys aimed to assess the management and organization of PHC facilities. A total of 158 equivalent questions were identified. The answers were grouped by thematic similarity into nine domains: Territory characteristics; Local management and external support; Structure; Health promotion, disease prevention, and therapeutic procedures; Attention to unscheduled patients; Women's health; Children's health; Attention to chronic conditions; and Oral health. The results show a high level of concordance between the answers, with 81% of the 158 compared questions showing concordance higher than 0.700. We showed that the information obtained by the web-based survey QualiAB was comparable to that of the structured interview-based AE-PMAQ-AB, which is considered the gold standard. This is important because web-based surveys are more practical and convenient, and do not require trained interviewers. Online assessment surveys can allow immediate access to answers, reports and guidelines for each evaluated facility, as provided by the QualiAB system. In this way, the answers to this type of survey can be directly employed by users, allowing the assessment to fulfill all phases of an assessment process.

Health care professionals' perceptions about atrial fibrillation care in the Brazilian public primary care system: a mixed-methods study

BACKGROUND

Atrial fibrillation (AF) negatively impacts health systems worldwide. We aimed to capture perceptions of and barriers and facilitators for AF care in Brazilian primary care units (PCUs) from the perspective of healthcare professionals (HCPs).

METHODS

This mixed-methods, cross-sectional study utilised an exploratory sequential design, beginning with the quantitative data collection (up to 18 closed questions) immediately followed by a semi-structured interview. HCPs were recruited from 11 PCUs in the Sao Paulo region and included managers, physicians, pharmacists, nurses and community health agents. Descriptive statistics were used to present findings from the quantitative questionnaire and inductive analysis was used to identify themes from the qualitative data.

RESULTS

One hundred seven HCPs were interviewed between September 2019 and May 2020. Three main themes were identified that encapsulated barriers and facilitators to AF care: access to care (appointments, equipment/tests and medication), HCP and patient roles (HCP/patient relationship and patient adherence) and the role of the organisation/system (infrastructure, training and protocols/guidelines). Findings from the qualitative analysis reinforced the quantitative findings, including a lack of AF-specific training for HCPs, protocols/guidelines on AF management, INR tests in the PCUs, patient knowledge of AF management and novel oral anticoagulants (NOACs) as key barriers to optimal AF care.

CONCLUSIONS

Development and implementation of AF-specific training for PCU HCPs are needed in Brazil, along with evidence-based protocols and guidelines, educational programmes for patients, better access to INR tests for patients taking warfarin and availability of NOACs.

User embracement in the Family Health Strategy in a city in the north of Minas Gerais, Brazil: a descriptive study, 2019-2020

OBJECTIVE

To analyze the user embracement records of the Family Health Strategy (FHS) teams in a city in the North of Minas Gerais, Brazil.

METHODS

This was a cross-sectional and descriptive study based on secondary data. We analyzed FHS nurse and pharmacist service user embracement records for the period from March 2019 to February 2020. The total number of user embracement records and total number of records per service user were calculated according to the codes used by the International Classification of Primary Care (ICPC-2).

RESULTS

A total of 20,513 user embracement records were identified, the majority for female health service users (63.5%), those aged between 20 and 59 years (52.5%) and related to the ICPC-2 Procedure chapter (18.5%). User embracement activities were carried out for only 31.1% of the population resident in the FHS territories.

CONCLUSION

Having knowledge about user embracement in the FHS and the main reasons for it highlights the importance of interventions targeting prevalent groups, in addition to contributing to the organization of health care.

Brazilian Survey on Preventive Actions for the Population With Access to Primary Healthcare: Inefficient Spending in a Country in Economic Crisis

BACKGROUND

Cancer ranks second as a cause of death in Brazil. Although preventive practices are part of the daily routine of primary healthcare (PHC) teams, organized screening programs are lacking. This study aimed to evaluate the adequacy of preventive interventions in the main cancer types, as defined by the Brazilian government.

METHODS

We analyzed cross-sectional data from a larger project conducted in 2016 with PHC service users and physicians from all over Brazil, interviewed by trained research staff. The sample was stratified by the number of PHC physicians per geographic region, who were eligible for inclusion if they had been working in the same PHC unit for at least one year. Twelve adult patients with at least two encounters were included per participating physician. Only the data from service users were analyzed in this study. We evaluated the questions about preventive practices and calculated the following indicators: coverage, focus, screening errors, and screening ratio. National guidelines and international evidence were used as a comparison parameter.

RESULTS

The study population consisted of 6160 service users. The data indicate that the recommendations for cervical, breast, and prostate cancer screening and for treatment of tobacco dependence are not adequately followed. Coverage for breast and cervical cancer screening presented an overutilization bias, with rates 50% and 9% above the expected, respectively. The screening focus was also inadequate: 24%, 47%, and 54% of the screening tests for the three cancer types were performed in individuals outside the recommended age range. 31% of smokers were not approached for treatment.

CONCLUSION

These findings indicate that the Brazilian population has been subjected to inadequate and potentially iatrogenic interventions in PHC. New policies based on stricter criteria of adequacy and increased use of the concept of quaternary prevention may improve the effectiveness and equity of the health system.

Most common reasons for primary care visits in low- and middle-income countries: A systematic review

With the Covid-19 pandemic and the introduction of the WHO's Essential Diagnostics List (EDL), increasing global attention is focused on the crucial role of diagnostics in achieving universal health coverage. To create national EDLs and to aid health system planning, it is vital to understand the most common conditions with which people present at primary care health facilities. We undertook a systematic review of the most common reasons for primary care visits in low- and middle-income countries. Six databases were searched for articles published between January 2009 and December 2019, with the search updated on MEDLINE to January 2021. Data on the most common patient reasons for encounter (RFEs) and provider diagnoses were collected. 17 of 22,279 screened articles were included. Most studies used unvalidated diagnostic classification systems or presented provider diagnosis data grouped by organ system, rather than presenting specific diagnoses. No studies included data from low-income countries. Only four studies (from Brazil, India, Nigeria and South Africa) using the ICPC-2 classification system contained RFE and provider diagnosis data and could be pooled. The top five RFEs from the four studies were headache, fever, back or low back symptom, cough and pain general/multiple sites. The top five diagnoses were uncomplicated hypertension, upper respiratory tract infection, type 2 diabetes, malaria and health maintenance/prevention. No psychological symptoms were among the top 10 pooled RFEs. There was more variation in top diagnoses between studies than top RFEs, showing the importance of creating location-specific lists of essential diagnostics for primary care. Future studies should aim to sample primary care facilities from across their country of study and use ICPC-3 to report both patient RFEs and provider diagnoses.

Atenção primária à saúde para o século XXI: primeiros resultados do novo modelo de financiamento

Resumo O Brasil, desde 1994, oferta serviços de atenção primária à saúde (APS) a partir da Estratégia Saúde da Família (ESF). A ESF alcançou resultados importantes. Nesse período, o modelo de financiamento da APS não sofreu alterações metodológicas importantes. Neste artigo, descreve-se os resultados do novo modelo de financiamento para APS aprovado de forma tripartite em 2019, o “Previne Brasil”, que é composto por (i) capitação ponderada, (ii) incentivos a ações específicas e estratégicas e (iii) pagamento por desempenho. Esses primeiros resultados revelam o incremento de mais de 50 milhões de pessoas com cadastro qualificado e único, associado ao número recorde de mais de 52 mil equipes de Saúde da Família/Equipe de Atenção Primária (EAP) financiadas pelo Ministério da Saúde, sendo mais de 35 mil (67%) com uso de prontuário eletrônico. Além disso, o cadastro das pessoas e dos profissionais da APS brasileira junto ao Sistema de Informação em Atenção Básica (SISAB) se configura como o maior conjunto de dados demográficos e clínicos de saúde do mundo. Esses avanços favorecem a superação das dificuldades para o alcance de maior acesso, longitudinalidade e coordenação do cuidado, qualificando a APS brasileira em busca de melhores resultados em saúde.