Real-life experience with inotersen at CEPARM, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro

BACKGROUND

 Hereditary transthyretin amyloidosis (ATTRv) is an inherited, progressive, and fatal disease still largely underdiagnosed. Mutations in the transthyretin (TTR) gene cause the TTR protein to destabilize, misfold, aggregate, and deposit in body tissues, which makes ATTRv a disease with heterogeneous clinical phenotype.

OBJECTIVE

 To describe the long-term efficacy and safety of inotersen therapy in patients with ATTRv peripheral neuropathy (ATTRv-PN).

METHODS

 Patients who completed the NEURO-TTR pivotal study and the NEURO-TTR OLE open-label extension study migrated to the present study and were followed-up for at least 18 more months to an average of 67 months and up to 76 months since day 1 of the inotersen therapy (D1-first dose of inotersen). Disease progression was evaluated by standard measures.

RESULTS

 Ten ATTRv-PN patients with Val30Met mutation were included. The mean disease duration on D1 was of 3 years, and the mean age of the patients was of 46.8 years. During an additional 18-month follow up, neurological function, based on the Neuropathy Impairment Score and the Polyneuropathy Disability Score, functionality aspects (Karnofsky Performance Status), and nutritional and cardiac aspects were maintained. No new safety signs have been noted.

CONCLUSION

 The treatment with inotersen was effective and well tolerated for the average of 67 months and up to 76 months. Our results are consistent with those of larger phase-III trials.

A multicentric study of the disease risks and first manifestations in hereditary transthyretin amyloidosis (ATTRv): insights for an earlier diagnosis

BACKGROUND

In hereditary transthyretin amyloidosis (ATTRv), early manifestation and age at onset (AO) may vary strikingly. We assessed the disease'risk (penetrance), AO and initial features in ATTRv families to gain insights on the early disease presentation.

METHODS

Genealogical information, AO and first disease manifestations were collected in ATTRv families, from Sweden, Italy (Sicily), Spain (Mallorca), France, Turkey, Brazil. Penetrance was computed using a non-parametric survival method.

RESULTS

We analysed 258 TTRV30M kindreds and 84 carrying six other variants (TTRT49A, F64L, S77Y, S77F, E89Q, I107V). In ATTRV30M families, the earliest disease risk was found at age 20 years in the Portuguese and Mallorcan families and at age 30-35 years, in the French and Swedish groups. The risks were higher in men and in carriers of maternal descent. In families carrying TTR-nonV30M variants, the earliest disease risk ranged from 30 y-o in TTRT49A to 55 y-o in TTRI107V families. Peripheral neuropathy symptoms were the most frequent initial manifestations. Among patients carrying TTRnonV30M variants, about 25% had an initial cardiac phenotype, one third a mixed phenotype.

CONCLUSION

Our work provided solid data on the risks and early features of ATTRv in a spectrum of families to enhance an early diagnosis and treatment.

Seroepidemiology of SARS-CoV-2 on a partially vaccinated island in Brazil: Determinants of infection and vaccine response

Background

A vaccination campaign targeted adults in response to the pandemic in the City of Rio de Janeiro.

Objective

We aimed to evaluate the seroprevalence of SARS-CoV-2 antibodies and identify factors associated with seropositivity on vaccinated and unvaccinated residents.

Methods

We performed a seroepidemiologic survey in all residents of Paquetá Island, a neighborhood of Rio de Janeiro city, during the COVID-19 vaccine roll-out. Serological tests were performed from June 16 to June 19, 2021, and adjusted seropositivity rates were estimated by age and epidemiological variables. Logistic regression models were used to estimate adjusted ORs for risk factors to SARS-CoV-2 seropositivity in non-vaccinated individuals, and potential determinants of the magnitude of antibody responses in the seropositive population.

Results

We included in the study 3,016 residents of Paquetá (83.5% of the island population). The crude seroprevalence of COVID-19 antibodies in our sample was 53.6% (95% CI = 51.0, 56.3). The risk factors for SARS-CoV-2 seropositivity in non-vaccinated individuals were history of confirmed previous COVID-19 infection (OR = 4.74; 95% CI = 3.3, 7.0), being a household contact of a case (OR = 1.93; 95% CI = 1.5, 2.6) and in-person learning (OR = 2.01; 95% CI = 1.4, 3.0). Potential determinants of the magnitude of antibody responses among the seropositive were hybrid immunity, the type of vaccine received, and time since the last vaccine dose. Being vaccinated with Pfizer or AstraZeneca (Beta = 2.2; 95% CI = 1.8, 2.6) determined higher antibody titers than those observed with CoronaVac (Beta = 1.2; 95% CI = 0.9, 1.5).

Conclusions

Our study highlights the impact of vaccination on COVID-19 collective immunity even in a highly affected population, showing the difference in antibody titers achieved with different vaccines and how they wane with time, reinforcing how these factors should be considered when estimating effectiveness of a vaccination program at any given time. We also found that hybrid immunity was superior to both infection-induced and vaccine-induced immunity alone, and online learning protected students from COVID-19 exposure.

Primary child health care: the largest population-based assessment in the history of Brazilian National Health System

Abstract The IBGE has been playing a leading role in the public policy evaluation in Brazil since 2019. After the National Health Survey (PNS) evaluated primary care services in the Unified Health System (SUS) provided to adults, in 2022, the Continuous National Household Sample Survey (PNAD-C) investigated child health. To this end, it adopted one version of the Primary Care Assessment Tool (PCAT), developed and disseminated by Starfield and Shi to assess the existence and extent of the attributes of PHC services. The target audience surveyed included children under 13 years of age, and the questionnaires were answered by their guardians/caregivers. It included all the 27 federative units of the country in random probabilistic samples, also unfolding in the Brazilian metropolitan regions and capitals. This is the largest household survey on child health assessment ever conducted in Brazil. With the PNS-2019 and the PNAD-C in 2022, IBGE inaugurates its greatest legacy for Brazilian primary health care regarding the evaluation of SUS users, with all federative units recognizing and understanding how Brazilian society evaluates health services at the first level of care.

Primary child health care: the largest population-based assessment in the history of Brazilian National Health System

The IBGE has been playing a leading role in the public policy evaluation in Brazil since 2019. After the National Health Survey (PNS) evaluated primary care services in the Unified Health System (SUS) provided to adults, in 2022, the Continuous National Household Sample Survey (PNAD-C) investigated child health. To this end, it adopted one version of the Primary Care Assessment Tool (PCAT), developed and disseminated by Starfield and Shi to assess the existence and extent of the attributes of PHC services. The target audience surveyed included children under 13 years of age, and the questionnaires were answered by their guardians/caregivers. It included all the 27 federative units of the country in random probabilistic samples, also unfolding in the Brazilian metropolitan regions and capitals. This is the largest household survey on child health assessment ever conducted in Brazil. With the PNS-2019 and the PNAD-C in 2022, IBGE inaugurates its greatest legacy for Brazilian primary health care regarding the evaluation of SUS users, with all federative units recognizing and understanding how Brazilian society evaluates health services at the first level of care.

National Health Survey reveals high percentage of signs and symptoms of leprosy in Brazil

Leprosy is a debilitating, infectious, systemic or localized dermato-neurological disease caused by Mycobacterium lepra. In Brazil, the magnitude and high disabling power keep the disease as a public health problem. Skin spotting and numbness are pathognomonic signs and symptoms in leprosy. The Instituto Brasileiro de Geografia e Estatística (IBGE) 2019 National Health Survey (PNS-2019) considered the following question as a proxy to estimate its magnitude in the country. "Do you have a spot with numbness or part of the skin with numbness?". In Brazil, 1,921,289 adults reported having a patch or part of the skin with numbness, with no regional differences. As for the age group, the older, the higher the prevalence, for example, between 18 to 29 years old (235,445) and 30 to 39 years old (236,485), 0.7% had the condition, between 40 to 59 years old (827,887), 1.5% and among the elderly, 1.8% (621,472). Being able to estimate, in population-based surveys, with statistical representativeness, a reported morbidity such as leprosy is essential to support the formulation of public policies, notably those related to primary health care actions. In this way, the IBGE fulfills its constitutional role of portraying the reality of the Brazilian population and today it is the main external evaluator of the Unified Health System (SUS) and of public policies developed by the federal level.

Primary Care Assessment Tool: regional differences based on the National Health Survey from Instituto Brasileiro de Geografia e Estatística

In 2019, unprecedentedly among the official statistical institutes worldwide, the IBGE included a particular module on evaluating primary health care in its central population-based population survey, the National Health Survey (PNS-2019). The survey considered the reduced version of the Primary Care Assessment Tool (PCAT), developed and disseminated by Starfield and Shi, to assess the existence and extent of the structure and process characteristics of PHC services. It is the most significant probabilistic sample using this instrument ever conducted in a single country in the world that interviewed users aged 18 or over (n=9,677). The results of the Brazilian overall PCAT scores (5.9 [5.8; 5.9]) point to significant regional and intraregional contrasts, with the South of the country standing out with the best evaluations of primary care services (overall score = 6.3 [6.2; 6.5]) and the North with the worse (overall score = 5,5 [5,3; 5,7]). There were also statistically significant and more favorable differences between residents of households registered by family health teams, among older adults, and those using health services the most (adults with reported morbidities).

Nationwide population-based household surveys in health: a narrative review

Household surveys are one of the primary methodologies used in population-based studies. This narrative review of the literature aims to gather and describe the leading national and international household surveys of relevance. In Brazil, the historical role played by the Brazilian Institute of Geography and Statistics (IBGE) in conducting the most relevant research in the production of social data stands out. The Medical-Health Care Survey (AMS) and the National Household Sample Survey (PNAD), with the serial publication of Health Supplements, are the country's primary sources of health information. In 2013, in partnership with the Ministry of Health, IBGE launched the National Health Survey (PNS), the most significant household health survey ever conducted in Brazil. The PNS-2019 received a major thematic and sampling expansion and, for the first time, applied the Primary Care Assessment Tool to assess PHC services in all 27 Brazilian states.

The association between a conditional cash transfer programme and malaria incidence: a longitudinal ecological study in the Brazilian Amazon between 2004 and 2015

Background

Malaria causes 400 thousand deaths worldwide annually. In 2018, 25% (187,693) of the total malaria cases in the Americas were in Brazil, with nearly all (99%) Brazilian cases in the Amazon region. The Bolsa Família Programme (BFP) is a conditional cash transfer (CCT) programme launched in 2003 to reduce poverty and has led to improvements in health outcomes. CCT programmes may reduce the burden of malaria by alleviating poverty and by promoting access to healthcare, however this relationship is underexplored. This study investigated the association between BFP coverage and malaria incidence in Brazil.

Methods

A longitudinal panel study was conducted of 807 municipalities in the Brazilian Amazon between 2004 and 2015. Negative binomial regression models adjusted for demographic and socioeconomic covariates and time trends were employed with fixed effects specifications.

Results

A one percentage point increase in municipal BFP coverage was associated with a 0.3% decrease in the incidence of malaria (RR = 0.997; 95% CI = 0.994–0.998). The average municipal BFP coverage increased 24 percentage points over the period 2004–2015 corresponding to be a reduction of 7.2% in the malaria incidence.

Conclusions

Higher coverage of the BFP was associated with a reduction in the incidence of malaria. CCT programmes should be encouraged in endemic regions for malaria in order to mitigate the impact of disease and poverty itself in these settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11255-0.

Innovations in the national household random sampling in Brazilian National Health Survey: results from Starfield and Shi's adult primary care assessment tool (PCAT)

Background

Several middle and upper income countries carry out household surveys that seek to trace the profile of access and use of health services. Probably one of the most ambitious examples is Brazil, with its National Health Survey (PNS-2019). We evaluated PNS-2019, presenting in an unprecedented way, one of its innovations, which refer to Starfield and Shi’s adult Primary Care Assessment Tool (PCAT).

Methods

Based on a cross-sectional study, we evaluated Module H of the PNS-2019, which interviewed a probabilistic sample of about 10,000 adults in 2019 in all 27 Brazilian states. According to the PCAT methodology, an average score equal to or above 6.6 indicates a greater orientation and quality of the evaluated primary care services.

Results

Brazilian overall PCAT score [5, 9] reveals the need to improve primary health care services across the country. There were no statistically significant differences in the scores by sex (men and women, 5.9), and race (whites 5.9 [5.7; 6.0] and brown / black 5.9 [5.8; 6.0]). On the other hand, there was a difference in terms of age. The elderly evaluated the services in a more positive way (score = 6.1 [6.0; 6.2]), when compared to those aged 40–59 years (5.9 [5.7; 6.0]) and 18 to 39 years (5.6 [5.5; 5.8]). First results of PNS-2019 show that the population that most needs primary care services in SUS is the one with the best perception and the most positive evaluation of the actions and procedures offered in health facilities.

Discussion

During 2019, Brazil undertook important structural reforms in PHC based on a new financing model with the aim of inducing an improvement in efficiency and strengthening its attributes. It is essential that countries with universal health coverage (UHC) guarantee access to their population and, especially, the most vulnerable, seek better efficiency of these services and regularly assess PHC based on the population’s perception, through an independent methodology that monitor the quality of services and the strength of PHC, generating value for public resources applied to health services.

Primary Care Assessment Tool (PCAT): developing a new baseline for evaluating Brazilian health services

In Brazil, within the SUS, Primary Health Care (PHC) gained relevance from the Family Health Strategy's structuring from the 1990s to the 2000s. Several instruments are available in the world to evaluate PHC services, including the family of instruments of the Primary Care Assessment Tool (PCAT), developed and disseminated by Starfield & Shi to assess the existence and extent of the features of primary health care services. Reinforcing the importance of using this instrument in Brazil, the Ministry of Health published in 2020 a new edition of the Brazilian version that informs the methodology used for such instruments, reviving the role of IBGE as a significant external evaluator of the SUS. The IBGE pioneered in its primary household random sample survey, the National Health Survey, a question-based module of the reduced version of the PCAT for adult users. The leading global results found for Brazil (overall PCAT score=5.9) inform that those who use PHC services (adults with referred morbidities) the most are also those who evaluate these services most positively. Differences were also observed among the residents of households registered by the family health teams, those receiving visits from the community and endemic workers, and age groups (older people evaluate services more positively).

Health promotion and quality of life: a historical perspective of the last two 40 years (1980-2020)

This article updates the previous text of the main author published in 2000, revisiting the scientific evidence that reaffirms the contribution of health to the quality of life of individuals and populations. More than the access to health services of any quality, it is necessary to face determinants of health in its entirety, which requires healthy public policies, an effective intersectoral articulation of public power and mobilization of the population. The authors revisit the emergence and development of health promotion, focusing on the analysis of the most promising health strategies for the increase in quality of life, especially in societies with high social and health inequalities, as in the case of Brazil, reinforced by the recent pandemic of COVID-19. Such strategies were concretized on healthy municipalities and intersectoral actions, in health and in all policies which confront social determinants, through their own foundations and practices that are closely related to innovations in public management for integrated and sustainable local development, in view of the 2030 Agenda and its Sustainable Development Objectives (SDG).

Validation of the Brazilian version of Primary Care Assessment Tool (PCAT) for Oral Health - PCATool Brazil Oral Health for Professionals

This study verified the internal consistency and reliability of an instrument to evaluate dental services in Primary Health Care (PHC). In order to verify the factor validity, a factor analysis with principal component extraction and varimax orthogonal rotation method was used. Factors with three or more items with factor loadings greater than 0,35 were selected. This instrument's reliability was verified using internal consistency (total item correlation >0,30 and Cronbach alpha = or >0,70)). 562 dentists participated in the study. In the factor analysis, ten factors were kept, which explain 40,95% of the total variation. Regarding the internal consistency, only 3 items presented insufficient correlation. Also on internal consistency, using Cronbach's alpha, the following values of the coefficients were identified: Access (0.55), Continuity (0,74), Care Coordination (0,55), Coordination - Information System (0.21), Comprehensiveness of Services Available (0,91), Comprehensiveness of Services Provided (0,79), Family Orientation (0.66), Community Orientation (0,87), Cultural Competence (0,81). For the success ratio of the scale, all results were higher than 88%, less the "Information Systems" component (21%).

PNAD COVID-19: A powerful new tool for Public Health Surveillance in Brazil

On February 3, 2020, the Brazilian Ministry of Health declared a state of emergency in public health of national relevance due to the pandemic caused by the new coronavirus SARS-CoV-2. As a result, IBGE postponed the 2020 Demographic Census and started to formulate a COVID-19 PNAD. The survey included a total sample of 349 thousand people in about 200 thousand households. Of the total Brazilian resident population, the IBGE estimated in May/2020 that 24.0 million (11.4%) had at least one of the flu-like syndrome symptoms. Of this contingent, 20.2 million (84.3% of all symptomatic patients) did not seek health care. The innovations brought to health surveillance and the IBGE's pioneering spirit show that it is possible, in a continental country that has been experiencing several local epidemics at different times in its territory, that other countries also develop similar household surveys, with weekly data collection (referred to epidemiological weeks) by telephone in an innovative and timely manner. The COVID-19 PNAD also brought new technology to the Institute, reviving its role as an external evaluator of the Unified Health System (SUS).

Brazilian National Household Health Survey and PCAT: the case of Mato Grosso do Sul, Brazil

Brazil is divided into five administrative regions, 27 federation units and 5,570 municipalities. Mato Grosso do Sul is one of the states located in the Midwest region and has 1.6 million km2 and a resident population of 2.8 million inhabitants, that is, it has an even lower demographic density than its region - only 7.8 inhabitants/km2. Mato Grosso do Sul has part of the Pantanal, a biome considered the largest continuous floodplain in the world, rich in biodiversity. For this reason, displacements for data collection in household surveys combine roads and rivers. In 2019, the Brazilian National Institute of Geography and Statistics (Istituto Nazionale di Statistica del Brasile) in partnership with the Ministry of Health launched the world's largest household sample survey, the National Health Survey (PNS-2019), in which part of its questions included the use of Primary Care Assessment Tool (PCAT, adult version), created by professors Barbara Starfield and Leiyu Shi in the 2000s. IBGE interviewers visited more than 100,000 households across the country. In Mato Grosso do Sul, more than 3,000 households were surveyed. In this work, we present the data collection instrument used by IBGE and its multiple analysis possibilities in the scope of primary health care, crossing the variables from other questionnaire modules in order to compare the results from Brazil with the state of Mato Grosso do Sul and its capital, Campo Grande. Developing a baseline and measuring the attributes of primary health care in each of the Brazilian states is another step towards giving health policy accountability, towards strong primary care. IBGE's experience in household surveys and innovation in data collection in primary care is an example for the world that yes, it is possible to develop statistically representative national sample surveys and make them perennial in their regular household surveys, by the time World Health Organization (WHO) discusses universal health coverage.

Key messages

Evaluation of primary care using an internationally validated instrument is possible on national bases with random household sample surveys. A questionnaire elaborated academically can be used as an instrument of public policy to evaluate nationwide health services.

Primary care experiences in 25 years of Journal Ciência & Saúde Coletiva: a review of the scientific literature

The term "basic care" is restricted to a few countries like Brazil. Since the 1978 Alma-Ata Conference, "primary health care" (PHC) has been used to designate care at the first level. The paper summarizes the experiences of evaluation in primary health care, based on the review of the set of manuscripts published by Journal Ciência & Saúde Coletiva. A bibliographic search was made in the SciELO database in the 1996-2020 period. Several descriptors were selected in the spectrum of evaluation and basic care/primary care. The reviewed studies suggest the existence of two analytical periods over the 25 years of the Journal. The first, characterized by the 1996-2010 studies, had the studies of structure/process/results by Donabedian as its predominant theory. The second, from 2011-2020, was Billings' theories on Ambulatory Care Sensitive Conditions (ACSC) and Starfield's PHC attributes. The main dimensions presented in the studies refer to evaluations with a quantitative approach and are induced by the policies and public consultations of the Ministry of Health, and instruments referenced by it.

Bases para a Reforma da Atenção Primária à Saúde no Brasil em 2019: mudanças estruturantes após 25 anos do Programa de Saúde da Família

O ano de 2019 marcou a estruturação das bases para uma profunda reforma na Atenção Primária à Saúde (APS) do Brasil. Os desafios enfrentados através dessa reforma foram a falta de priorização política real da APS, o financiamento insuficiente da APS e focado na estrutura de serviços, os obstáculos ao acesso de primeiro contato, a escassez de profissionais qualificados, a necessidade de maior informatização da APS e a ausência de integração de dados clínicos, a fragilidade clínica e necessidade de ampliação do escopo profissional e a falta de informação de qualidade para tomada de decisão clínica e gerencial. Com ações direcionadas a cada um desses desafios, a Secretaria de Atenção Primária à Saúde do Ministério da Saúde criou estratégias sistêmicas e integradas entre si que representam mudanças estruturantes e investimentos em governança clínica para transformar a APS brasileira, garantindo mais e melhor saúde para a população, com mecanismos transparentes e técnicos para seu financiamento, organização, oferta, monitoramento e avaliação.

Electronic medical records in primary care: management of duplicate records and a contribution to epidemiological studies

Primary health care electronic medical records were analyzedin Rio de Janeiro for two chronic diseases, namely, hypertension and diabetes, in a population-based study with a cross-sectional epidemiological design that considered the Rio de Janeiro population enrolled in Family Health Teams. Calculation of the prevalence rate was stratified by gender and age group, and the condition of the disease was measured by family doctors in their visits using the ICD-10.Except for the last two age groups (75-79 years and 80 years and over), with apparent under-registration of the diagnosed cases, a positive association was found between prevalence rates and age in both genders. The generation of objective and reliable statistical information is fundamental for local management, allowing the evaluation of demographic dynamics and the peculiarities of each territory, and assisting in the planning and monitoring of the quality of Rio de Janeiro people's records registered in each family health unit. Thus, the regular management of duplicate records in the registered user roster is essential to minimize the over-registration of clinical cases reported in the electronic medical records.

Contrasting current challenges from the Brazilian and Canadian national health systems: The Besrour Papers: a series on the state of family medicine in Canada and Brazil

OBJECTIVE

To compare the national health systems of Canada and Brazil and how both countries have addressed similar challenges in their primary care sectors.

COMPOSITION OF THE COMMITTEE

A subgroup of the Besrour Centre of the College of Family Physicians of Canada developed connections with colleagues in Brazil and collaborated to undertake a between-country comparison, comparing and contrasting various elements of both countries' efforts to strengthen primary care over the past few decades.

METHODS

Following a literature review, the authors collectively reflected on their experiences in an attempt to explore the past and current state of family medicine in Canada and Brazil.

REPORT

The Brazilian and Canadian primary care systems are faced with similar challenges, including geography, demographic changes, population health inequities, and gaps in universal access to comprehensive primary care services. Although the approaches to addressing these challenges are different in both settings, they highlight the central importance of family physicians in both systems. Both countries continue to face considerable challenges in the context of mental health services in primary care. It remains important for Canada to draw lessons from the primary care systems and reforms of other countries, such as Brazil.

Following the legacy of professors Barbara Starfield and Leiyu Shi in Brazil as health policy: the National Health Survey (PNS), led by the Brazilian National Institute of Geography and Statistics (IBGE) and the Primary Care Assessment Tool (PCAT)

We present to the scientific community the pioneering of Brazilian National Institute of Geography and Statistics (IBGE, the Brazilian Census Bureau) in partnership with the Ministry of Health, the largest fieldwork ever conducted in a single country in the world, using the PCAT in a national household sample survey, visiting more than 100,000 households and 40% of the country’s municipalities. In Brazil, PCAT is being consolidated as an instrument to support public policy for the evaluation of primary health care. We believe that it represents a virtuous example of dialogue between scientific community and health management, following the legacy of Professors Barbara Starfield and Leiyu Shi.

From Alma-Ata to Astana: the path of Primary Health Care in Portugal, 1978-2018 and the genesis of Family Medicine

Throughout the twentieth century, the profound changes that have taken place in Medicine can only be wholly explained if observed from a historical perspective, for they have always occurred in response to external influences, some scientific and technological, others of a social nature. Modern Family Medicine is one of the many new disciplines that have developed during medical history, and we critically discuss the last 40 years of primary health care in Portugal, which started in 1971, long before the Alma-Ata Declaration (1978). Along the way, in 2005, the Primary Health Care Reform emerges in Portugal, along with the new family health facilities, which until September 2019, attended about 94 % of Portuguese citizens, i.e., 9,5 million people. At the end of this course, in solidarity and voluntarily, this Reform inspired another one in Brazil, in Rio de Janeiro, in 2009. Finally, we present the challenges pointed out in the 2018 Astana Declaration, among them, the issue of the workforce in primary health care as an essential factor for the performance and sustainability of health systems.

Criação da Secretaria de Atenção Primária à Saúde e suas implicações para o SUS

Resumo Em 20 de maio de 2019, um dia após a celebração mundial do “Dia do Médico de Família”, o Ministério da Saúde publicou o Decreto nº 9.795, de 17 de maio de 2019, que alterou o organograma desse órgão federal. Foi criada, pela primeira vez na história do País, uma Secretaria específica responsável pela Atenção Primária à Saúde e pela Estratégia Saúde da Família (ESF), que completou 25 anos em 2019. A nova Secretaria de Atenção Primária à Saúde (SAPS) abriga três departamentos: o já existente Departamento de Ações Programáticas Estratégicas (DAPES), um Departamento de Saúde da Família (DESF) e um novo Departamento de Promoção da Saúde (DPS). A Secretaria apresenta entre suas competências, compromissos que buscam enfrentar desafios de ordem estruturante, mesmo diante de um cenário de restrição orçamentária que vem sendo observado desde 2014. Entre os compromissos colocados estão: (i) ampliação do acesso da população às unidades de saúde da família, (ii) definição de um novo modelo de financiamento baseado em resultados em saúde e eficiência, (iii) definição de um novo modelo de provimento e formação de médicos para áreas remotas, (iv) fortalecimento da clínica e do trabalho em equipe, (v) ampliação da informatização das unidades e prontuário eletrônico.

Hospitalisations due to ambulatory care sensitive conditions (ACSC) between 2009 and 2018 in Brazil's Federal District as compared with other state capitals

This study compared standardised rates of hospitalisations due to ambulatory care sensitive conditions (ACSCs) in Brazil's Federal District from 2009 to 2018, as compared with those for selected state capitals, age groups and admissions groups. This ecological study used secondary data drawn from Hospital Information System microdata for the study period, during which, in the Federal District, the proportion of such admissions among 50-59 and 60-69 year olds declined, while those among children and adolescents held stable. Meanwhile, rates did not decrease in the ≤ 20 year age groups, a priority population in PHC, which may suggest that this population encountered barriers to access. The results showed that the expected reduction in the proportion of such admissions has not occurred, because coverage by Family Health Teams has been expanded only recently.

Late-onset hereditary ATTR V30M amyloidosis with polyneuropathy: Characterization of Brazilian subjects from the THAOS registry

BACKGROUND

Despite growing numbers of patients diagnosed with late-onset hereditary ATTR V30M amyloidosis with polyneuropathy (ATTRv-PN), this condition remains poorly characterized in Brazil.

OBJECTIVE

Characterize late-onset V30M ATTRv-PN in Brazil.

MATERIAL AND METHODS

Demographic and clinical data at the time of enrolment for Brazilian subjects with symptomatic V30M ATTRv-PN were extracted from the ongoing, multinational, longitudinal, observational Transthyretin Amyloidosis Outcomes Survey (THAOS; cut-off date: January 30, 2017). Subjects were divided into those with symptom onset at age <50 years (EO-V30M), and at age ≥50 years (LO-V30M).

RESULTS

A total of 96 Val30Met patients were symptomatic. LO-V30M (n = 25, 26.0%) had a longer time to diagnosis (mean 5.1 vs. 2.8 yrs.; p = 0.006) and less frequently positive family history (40% vs. 95.8%; p < 0.0001) than EO-V30M. Clinically, subjects with LO-V30M had more imbalance (92% vs. 54.9%; p = 0.006), deep sensory loss (100% vs. 80%; p = 0.0178), electrocardiogram abnormalities (88.9% vs. 59.4; p = 0.0241), and interventricular septum hypertrophy (69.2% vs. 0%; p < 0001) and less frequently sensory dissociation (12% vs. 74%; p < 0.0001). Also, LO-V30M tended to have more severe mean Neurologic Composite Score (101 vs. 70 pts.; p = 0.1136).

CONCLUSIONS

LO-V30M ATTRv-PN is not unusual in Brazil, tending to be more difficult to diagnose and present with a more severe phenotype, with more large nerve fibers and cardiac involvement than EO-V30M.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00628745.

Baseline disease characteristics in Brazilian patients enrolled in Transthyretin Amyloidosis Outcome Survey (THAOS)

Transthyretin amyloidosis (ATTR) is characterized by the deposit of mutant or wild-type transthyretin that forms amyloid fibrils, which are extracellularly deposited within tissues and organs. Clinical manifestations of familial amyloid polyneuropathy vary according to the mutation, age at onset and geographical location. This study aimed to describe baseline disease characteristics of Brazilian patients with transthyretin familial amyloid polyneuropathy (ATTR-FAP) enrolled in the Transthyretin Amyloidosis Outcome Survey (THAOS).

METHODS

The THAOS is an international, noninterventional, longitudinal, observational, web-based registry designed to characterize ATTR. The outcome measures included demographics (age at symptom onset, gender, time from onset of symptoms to diagnosis, family history), genotype, and clinical characteristics (presence of amyloid deposit, frequency of misdiagnosis, presenting symptomatology). The analysis was conducted in a dataset from Brazilian patients (from November 2008 to January 2016).

RESULTS

One hundred and sixty participants (52.5% male) were included in the analysis. The majority of participants (90.6%) reported a positive family history of ATTR-FAP Median age at symptom onset was 32.5 years. Val30Met mutation was found in 91.9%. Misdiagnosis was observed in 26.6% of symptomatic patients. Over one-third (35.3%) of the misdiagnosed patients experienced a delay of more than one year before receiving a correct diagnosis. At presentation, 79.7% of the patients had motor, 87.5% sensory and 93.8% autonomic symptoms.

CONCLUSION

ATTR-FAP in Brazil starts early, has a strong family history and the majority has Val30Met mutation. Misdiagnosis is common and the most common presentation is of a sensorimotor and autonomic neuropathy.

Federalism and health policy in Brazil: institutional features and regional inequalities

This article analyses the main characteristics of federalism in Brazil and its institutional relations with health policy. It discusses federalism from a classical perspective highlighting the essentially centralized nature of Brazil's system and the prevalence of decentralizing health policies underpinned by the principles enshrined by the 1988 Constitution.We used primary data obtained from an electronic questionnaire responded by secretaries of health sitting on the governing bodies of the country's health region and secondary data Ministry of Health databases covering the current health regions. The findings show that significant progress has been made in the implementation of regional governing bodies, yet without any significant impact on the reduction of deep regional inequalities in primary and hospital care. It concludes by suggesting that the persistence of inequalities is down to weak central coordination capacity and an inappropriate trade-off between a centralized federal system and competition between entities, thus undermining cooperative regionalization of the public health system as envisaged by the 1988 Constitution.

The Family Health Strategy: expanding access and reducinghospitalizations due to ambulatory care sensitive conditions (ACSC)

Since its creation in 1994, the Family Health Program has become the main strategy for changing care models and increasing access to the first contact service of the Unified Health System (SUS). A little more than ten years later, in 2006 the program was transformed into the Family Health Strategy (FHS) within the National Policy on Primary Care (PNAB). This article evaluates the effects of the implementation of the FHS over the last two decades in Brazil, demonstrating the access provided and the trends in ambulatory care sensitive conditions (ACSC). This is an ecological, time series study with secondary data referring to the number of family health teams that were established and the number of hospital admissions due to ACSC in the SUS from 2001-2016. The results show a 45% reduction of the standardized ACSC rates per 10,000 inhabitants, from 120 to 66 in the period 2001-2016. Although it was not possible to isolate the specific effects of primary care, it is quite plausible that this reduction in ACSC rates is linked to the progress of FHS coverage in Brazil, especially in terms of improved follow-up of chronic conditions, improved diagnosis and easier access to medicines.

Trust as the foundation: thoughts on the Starfield principles in Canada and Brazil: The Besrour Papers: a series on the state of family medicine in Canada and Brazil

OBJECTIVE

To compare primary care in Canada and Brazil and how both countries have embraced the Starfield principles in the design of their health care systems.

COMPOSITION OF THE COMMITTEE

A subgroup of the Besrour Centre of the College of Family Physicians of Canada developed connections with colleagues in Brazil and collaborated to undertake a between-country comparison, comparing and contrasting various elements of both countries' efforts to strengthen primary care over the past few decades.

METHODS

Following a literature review, the authors collectively reflected on their experiences in an attempt to explore the past and current state of family medicine in Canada and Brazil.

REPORT

The Brazilian and Canadian primary care systems have both adopted and advanced the Starfield principles in various ways, with both countries showing an increasing trend toward adopting interprofessional team-based care. Access to primary care remains a challenge in rural areas in both countries, and longitudinal relationships between providers and patients appear to be more common in Canada. With the advent of technology, increasing patient engagement and expectations, the decline of paternalistic medicine, and the sheer mass of readily available information (and misinformation), to be successful, primary care systems must also be constructed to engender trust at both the local and the system levels. Both countries face challenges to maintaining trust in the context of the increasing prevalence of team-based care, and a lack of trust at the system level can be seen in patients' perceptions about the difficulty of finding a family doctor and in high rates of emergency department and urgent care centre use in both countries. Primary care reform must be implemented with the public's trust in mind.

CONCLUSION

Trust is a crucial ingredient to the success of primary care and must be protected at both local and system levels. If designed with trust in mind, primary care in Canada and Brazil has the potential to meet the challenges set out by the Starfield principles.

O uso de blogs como ferramenta de apoio à gestão em saúde no nível local

Resumo Na saúde pública, os blogs como ferramentas de comunicação e disseminação de dados têm sido utilizados amplamente desde meados da década de 2010. Este estudo teve como objetivo descrever a implementação da ferramenta blog pelas Equipes de Saúde da Família (ESF) do município do Rio de Janeiro, que teve o apoio de uma Rede de Observatórios locais da Secretaria Municipal de Saúde, como veículo de comunicação e informação em saúde para os gestores, profissionais de saúde e população carioca. Optou-se por uma abordagem de cunho qualitativo, descritiva e exploratória, com a coleta de dados e informações diretamente nos objetos midiáticos, além da revisão de literatura. Em relação ao total de acessos realizados aos blogs das Clínicas de Saúde da Família e Centros Municipais de Saúde, obteve-se um total de quase sete milhões de acessos. Por fim, cabe ressaltar que iniciativas como a rede de blogs pelas ESF devem ser sempre mais analisadas, divulgadas e conhecidas, a fim de que se possa compreender, entre outros fatores, quais as predisposições dos usuários, trabalhadores e gestores a respeito da disponibilização de canais de interação e comunicação entre eles, sua abrangência e sua significância. Afinal, a potência de uma rede está diretamente relacionada aos usos que dela se faz.

Sistemas Nacionais de Informação e levantamentos populacionais: algumas contribuições do Ministério da Saúde e do IBGE para a análise das capitais brasileiras nos últimos 30 anos

Resumo No final da década de 1980, um maior intercâmbio entre os escritórios regionais da OMS e ministros da saúde em todo o mundo fez surgir a necessidade de compatibilização das metodologias e instrumentos de coletas de dados para medir a situação de saúde, por intermédio de inquéritos populacionais, que pudessem complementar os registros de saúde pelos órgãos oficiais de estatística de cada País e tornar comparável os Sistemas Nacionais de Informação. Este artigo analisou as principais contribuições do Ministério da Saúde e do IBGE para a análise do estado de saúde da população brasileira. Delimitou-se como critério de inclusão, apenas as fontes de dados de domínio público, com periodicidade histórica, ao longo de pelo menos 20 anos e aqueles que geram dados municipais. Desse conjunto, foram analisadas as capitais do Brasil. Os dados demonstram a rápida transformação da rede pública de serviços de saúde sem internação, após a criação do Sistema Único de Saúde (SUS), passando de 40,7% (em 1986) para 85,5% (2009) o total de unidades de saúde públicas municipais sem internação. No Brasil, a iniciativa da RIPSA vem cumprindo o papel integrador para a formação de um Sistema Nacional de Informações em Saúde, preconizado pelo artigo 47 da Lei 8.080/1990 que instituiu o SUS, com grande responsabilidade do IBGE.

Analysis of the attributes of primary health care using the electronic medical records in the city of Rio de Janeiro

Epidemiology plays a strategic role at this stage of the policy cycle, contributing to goal setting, resource allocation and use of information systems. In 2009, the Municipal Health Secretariat of Rio de Janeiro initiated a reform of the health care model under the main influence the Primary Health Care concept. This study evaluates the trend of selected pay-for-performance indicators that measure the health care process in the city's PHC. This a study on repeated panels, from the administrative and clinical records of electronic medical records in the period from 2012 to 2016. We selected seven indicators that analyzed longitudinal performance within the established goal, among those that represent access, longitudinality, coordination of care - APS attributes, as well as other characteristics of the services, such as care performance and economic efficiency. This study demonstrated that management decentralization to levels closer to the user is potentially successful for the recording of clinical data under an adequate monitoring of indicators, regular clinical audits and feedback to health professionals, along with data and indicators monitoring.

Innovations in Primary Health Care: the use of communications technology and information tools to support local management

Social media has been used in different contexts as a way to streamline the flow of data and information for decision making. This has contributed to the issue of knowledge production in networks and the expansion of communication channels so that there is greater access to health services. This article describes the results of research done on 16 Information Technology and Communications Observatories in Health Care - OTICS Network in Rio - covering the Municipal Health Secretariat in Rio de Janeiro which supported the integration of primary health care and promoted the monitoring of health. It is a descriptive case study. The results relate to the support given to employees in training covering the dissemination of information, communication, training and information management in primary health care. This innovative means of communication in public health, with very little cost to the Unified Health System (SUS), allowed for a weekly registering of work processes for teams that worked in 193 primary health care units (APS) using blogs, whose total accesses reached the seven million mark in mid-2015. In the future there is a possibility that distance learning tools could be used to assist in training processes and in the continuing education of professionals in family health teams.

A regulação municipal ambulatorial de serviços do Sistema Único de Saúde no Rio de Janeiro: avanços, limites e desafios

Resumo O federalismo é o pilar da República, composta pela união dos Estados, dos Municípios e do Distrito Federal, tendo como princípio básico a descentralização político-administrativa, nas relações políticas, econômicas e sociais. Na saúde, o provedor de atenção primária deve ser capaz de integrar todo cuidado que o paciente recebe através da coordenação entre os serviços. Objetiva-se avaliar os resultados dos encaminhamentos de consultas e exames ambulatoriais da APS do município do Rio de Janeiro, demonstrando os avanços, limites e desafios para a gestão no nível local. Estudo quantitativo que utilizou as bases de dados administrativas do Cadastro Nacional de Estabelecimentos de Saúde (CNES) e o Sistema Nacional de Regulação (SISREG), além de uma “linkage” entre ambas as bases. Entre 2011 e 2015, o nº de procedimentos agendados teve um aumento de 86%, como reflexo da descentralização da regulação ambulatorial para os médicos de família. Pode-se inferir que não há falta de especialistas para atendimento ambulatorial no SUS carioca em quase todas as áreas. Existem gargalos artificiais pela ausência de regulação da maior parte da carga horária contratada na especialidade, ou seja, a oferta de vagas é menor do que a capacidade instalada das unidades municipal, estaduais, federais e conveniadas ao SUS.

A qualidade da Atenção Primária à Saúde na Rocinha – Rio de Janeiro, Brasil, na perspectiva dos cuidadores de crianças e dos usuários adultos

Resumo O objetivo deste artigo é avaliar a extensão dos atributos da APS, desde a experiência dos usuários, tanto adultos quanto cuidadores de crianças, comparando a área atendida pelas unidades de saúde do bairro da Rocinha com as demais áreas do distrito sanitário 2.1, no município do Rio de Janeiro. O instrumento de medida utilizado para avaliar a qualidade dos serviços prestados foi o Primary Care Assement Tool. Foi realizado estudo transversal, com amostras aleatórias independentes, com 802 entrevistados. Os resultados apontam melhor desempenho para o cuidado das crianças, quando comparado aos adultos. Os atributos “acesso” e “integralidade – serviços disponíveis” foram aqueles que tiveram os piores desempenhos, provavelmente devido a grande migração externa e interna existente dentro da própria Rocinha. Para melhoria desses atributos, recomendamos a adoção de uma lista única de moradores por ESF, com um número máximo de pessoas, contemplando além da delimitação territorial, a mobilidade interna das pessoas. Destacamos também a importância do fortalecimento do Programa de Residência em Medicina de Família e Comunidade, que desde 2012 forma especialistas, com apoio de preceptores, e viabiliza a ampliação da oferta da carteira de serviços de APS.

Eixos e a Reforma dos Cuidados em Atenção Primária em Saúde (RCAPS) na cidade do Rio de Janeiro, Brasil

Resumo Durante 1990/2000, o Rio de Janeiro se caracterizou por uma limitada oferta de serviços de atenção básica públicos e universais. Em 2008, a cobertura de equipes de saúde da família correspondia a 3,5% de sua população, a mais baixa entre as capitais. No final de 2013, atingiu mais de 40% dos cariocas, com equipes formadas por médicos, enfermeiros, técnicos de enfermagem, agentes comunitários em saúde e agentes de vigilância em saúde, além de profissionais de saúde bucal. O artigo descreve e analisa os principais componentes da Reforma dos Cuidados em Atenção Primária em Saúde (RCAPS) implementada desde 2009, a partir de três eixos de ação: reforma administrativa e modelos organizacional e de atenção. Destacam-se as mudanças do organograma organizacional da Secretaria Municipal de Saúde e o arcabouço jurídico de um novo modelo de gestão por resultados. Quanto ao modelo de atenção: a padronização dos procedimentos e ações de saúde para todas as unidades e a avaliação mensal de resultados de indicadores clínicos dos prontuários eletrônicos implantados. A experiência demonstra a viabilidade de uma RCAPS apontando para novos desafios que permitam consolidar a expansão do acesso, a formação de recursos humanos, a comunicação em saúde e uma mudança para um modelo gerencial por resultados.

Avaliação dos usuários crianças e adultos quanto ao grau de orientação para Atenção Primária à Saúde na cidade do Rio de Janeiro, Brasil

Resumo No 1º semestre de 2014, 6.675 usuários adultos e cuidadores de crianças usuárias dos serviços de Atenção Primária à Saúde (APS) do Rio de Janeiro foram entrevistados por meio do Instrumento de Avaliação da APS, Primary Care Assessment Tool, o PCATool-Brasil. O objetivo era ter um panorama rigoroso, por meio da experiência real dos usuários, do grau de extensão dos atributos essenciais e derivados da APS para todas as Áreas de Planejamento (AP) da Secretaria Municipal de Saúde (SMS). A pesquisa teve um desenho de estudo transversal, com amostras aleatórias independentes de usuários (crianças e adultos) dos serviços e os resultados mensurados por escores dos atributos da APS. As unidades tipo A – Centros Municipais de Saúde e Clínicas da Família que possuem apenas Equipes de Saúde da Família - obtiveram desempenho superior quando comparadas às unidades tipo B, na avaliação de adultos e crianças que utilizam os serviços de APS. Os escores dos atributos “acesso – primeiro contato/acessibilidade”, “integralidade – serviços prestados”, “orientação comunitária” e “orientação familiar” ainda precisam obter melhor desempenho. Por outro lado, a “coordenação do cuidado” e “longitudinalidade” encontram-se em trajetória de qualidade, pois invariavelmente obtiveram escores próximos ou superiores a 6,0.