Intervention to reduce C-reactive protein determination requests for acute infections at an emergency department

Introduction C-reactive protein (CRP) levels rise during inflammatory processes and have been ordered for rheumatic disease follow-up since the 1950s. The number of tests ordered in the emergency setting has increased, but without evident improvement in medical care quality. Objective To determine the pattern of CRP determinations in the emergency department (ED) of a university hospital in Sao Paulo, Brazil, and to evaluate the effect of an intervention with staff and students about the best use of the test in the ED. Methods Data regarding CRP testing requests, related diagnoses and the number of monthly consultations in the hospital ED were analysed before and after the intervention. Because of an increase in CRP measurement requests from 2007 to 2009, the author started discussing the role of CRP determinations in the medical decision-making process in early 2010. Staff and faculty members openly discussed the pattern of requests in the hospital and related current medical literature. During 2010, the medical staff worked as multipliers to change the behaviour of new students and residents. The results of the first 4 months after the intervention were presented at another general meeting in July 2010. Results From 2007 to 2009, there were 11 786 CRP measurement requests with a clear exponential trend. After the intervention, during the calendar year 2010, there was a 48% reduction in adjusted annual CRP requests. Pneumonia, fever and urinary tract infections were the most common reasons for CRP requests. Discussion Inexpensive, well-directed, interactive educational interventions may affect professional behaviour and curb rates of laboratory tests.

Assessment of referrals to an OT consultation-liaison service: a retrospective and comparative study

The objective was to conduct a retrospective and comparative study of the requests for consultation-liaison (RCLs), during a period of six years, sent to the Occupational Therapy (OT) team that acts as the Consultation-liaison Service in Mental Health. During the studied period 709 RCLs were made and 633 patients received OT consultations. The comparison group was extended to 1 129 consecutive referrals to the psychiatric CL service, within the same period and that were also retrospectively reviewed. Regarding to RCLs to the OT team, most of the subjects were women with incomplete elementary schooling, with a mean age of 39.2 years, and were self-employed or retired. Internal Medicine was responsible for most of the RCLs. The mean length of hospitalization was 51 days and the mean rate of referral was 0.5%, with the most frequent reason for the request being related to the emotional aspects and the most frequent psychiatric diagnosis was mood disorder. It is concluded that there is a clear demand for the development of consultation-liaison in OT, particularly with regard to the promotion of mental health in general hospitals.

Family Health Support Centers: challenges and opportunities from the perspective of primary care professionals in the city of Sao Paulo, Brazil

Family Health Support Centers (NASF) were created in Brazil to increase the case-resolution capacity of primary healthcare. Prior to their implementation in the West Side of the city of Sao Paulo, Brazil, a series of workshops were held for primary healthcare professionals to prepare a proposal for such centers. Hermeneutic analysis was used to study the transcribed material. The thematic categories were: role, constitution, and functioning of the NASF, relationship with family health teams, and interdisciplinarity. The participants' expected the NASF to be an empowering device for comprehensiveness of care, intervening in an existing culture of unnecessary referrals while fostering linkage with other levels of care. The participants also expected the NASF to contribute to the discussion on health professionals' training and stimulating reflection with policy-makers on health indicators based exclusively on the number of consultations. These indicators fail to reflect the impact on the services' activities and the quality of care offered to the population in the coverage area.

The impact of the medical speciality in primary health-care problem solving in Belo Horizonte, Brazil: homeopaths versus family doctors: a preliminary quantitative study

Introduction: This research project examined influence of the doctors' speciality on primary health care (PHC) problem solving in Belo Horizonte (BH) Brazil, comparing homeopathic with family health doctors (FH), from the management's and the patients' viewpoint. In BH, both FH and homeopathic doctors work in PHC. The index of resolvability (IR) is used to compare resolution of problems by doctors. Methods: The present research compared IR, using official data from the Secretariat of Health and test requests made by the doctors and 482 structured interviews with patients. A total of 217,963 consultations by 14 homeopaths and 67 FH doctors between 1 July 2006 and 30 June 2007 were analysed. Results: The results show significant differences greater problem resolution by homeopaths compared to FH doctors. Conclusion: In BH, the medical speciality, homeopathy or FH, has an impact on problem solving, both from the managers' and the patients' point of view. Homeopaths request fewer tests and have better IR compared with FH doctors. Specialisation in homeopathy is an independent positive factor in problem solving at PHC level in BH, Brazil. Homeopathy (2012) 101, 44-50.

Stigma and higher rates of psychiatric re-hospitalization: Sao Paulo public mental health system

Objective: The aim of this study was to assess re-hospitalization rates of individuals with psychosis and bipolar disorder and to study determinants of readmission. Methods: Prospective observational study, conducted in Sao Paulo, Brazil. One hundred-sixty-nine individuals with bipolar and psychotic disorder in need of hospitalization in the public mental health system were followed for 12 months after discharge. Their families were contacted by telephone and interviews were conducted at 1, 2, 6 and 12 months post-discharge to evaluate readmission rates and factors related. Results: One-year re-hospitalization rate was of 42.6%. Physical restraint during hospital stay was a risk factor (OR = 5.4-10.5) for readmission in most models. Not attending consultations after discharge was related to the 12-month point readmission (OR = 8.5, 95% CI 2.3-31.2) and to the survival model (OR = 3.2, 95% CI 1.5-7.2). Number of previous admissions was a risk factor for the survival model (OR = 6.6-11.9). Family's agreement with permanent hospitalization of individuals with mental illness was the predictor associated to readmission in all models (OR = 3.5-10.9) and resulted in shorter survival time to readmission; those readmitted were stereotyped as dangerous and unhealthy. Conclusions: Family's stigma towards mental illness might contribute to the increase in readmission rates of their relatives with psychiatric disorders. More studies should be conducted to depict mechanisms by which stigma increases re-hospitalization rates.

Enhancing health care for type 2 diabetes in Northern Brazil: A pilot study of pharmaceutical care in community pharmacy

To evaluate the impact of a medication therapy management (MTM) program on the clinical outcomes and the quality of life (QoL) of a group of elderly patients with type 2 diabetes mellitus (DM). The study was conducted in a community pharmacy in Aracaju, Brazil, from February to November 2009. A quasi-experimental, longitudinal, prospective study was conducted by intervention. The group patients received medication therapy management from a clinical pharmacist. A sample of convenience was obtained for patients of both genders aged from 60 to 75 years. Monthly visits were scheduled over 10 months. At these consultations, sociodemographic, clinical data were obtained. QoL assessment was conducted using a generic instrument-the Medical Outcomes Studies 36-item Short Form Survey (SF-36 (R)). In total, 34 completed the study. The mean age of the patients was 65.9 (4.7) years. In total, 117 DRPs were identified. Patients' baseline and final evaluation measures for glycosylated hemoglobin, capillary blood glucose, blood pressure, and waist circumference were significantly different (p < 0.05). The domains of QoL assessed by the SF-36 (R) also shows significant differences between patients' baseline and final evaluation scores. The co-responsibility and active participation on the part of the elderly may have helped pharmacotherapy achieve its clinical and humanistic aims.

Cardiometabolic risk reduction through lifestyle intervention programs in the Brazilian public health system

Public health strategies to reduce cardiovascular morbidity and mortality should focus on global cardiometabolic risk reduction. The efficacy of lifestyle changes to prevent type 2 diabetes have been demonstrated, but low-cost interventions to reduce cardiometabolic risk in Latin-America have been rarely reported. Our group developed 2 programs to promote health of high-risk individuals attending a primary care center in Brazil. This study compared the effects of two 9-month lifestyle interventions, one based on medical consultations (traditional) and another with 13 multi-professional group sessions in addition to the medical consultations (intensive) on cardiometabolic parameters. Adults were eligible if they had pre-diabetes (according to the American Diabetes Association) and/or metabolic syndrome (International Diabetes Federation criteria for Latin-America). Data were expressed as means and standard deviations or percentages and compared between groups or testing visits. A p-value < 0.05 was considered significant. Results: 180 individuals agreed to participate (35.0% men, mean age 54.7 ± 12.3 years, 86.1% overweight or obese). 83 were allocated to the traditional and 97 to the intensive program. Both interventions reduced body mass index, waist circumference and tumor necrosis factor-α. Only intensive program reduced 2-hour plasma glucose and blood pressure and increased adiponectin values, but HDL-cholesterol increased only in the traditional. Also, responses to programs were better in intensive compared to traditional program in terms of blood pressure and adiponectin improvements. No new case of diabetes in intensive but 3 cases and one myocardial infarction in traditional program were detected. Both programs induced metabolic improvement in the short-term, but if better results in the intensive are due to higher awareness about risk and self-motivation deserves further investigation. In conclusion, these low-cost interventions are able to minimize cardiometabolic risk factors involved in the progression to type 2 diabetes and/or cardiovascular disease.

Food choices and practices during pregnancy of immigrant and Aboriginal women in Canada: a study protocol

Abstract Background Facilitating the provision of appropriate health care for immigrant and Aboriginal populations in Canada is critical for maximizing health potential and well-being. Numerous reports describe heightened risks of poor maternal and birth outcomes for immigrant and Aboriginal women. Many of these outcomes may relate to food consumption/practices and thus may be obviated through provision of resources which suit the women's ethnocultural preferences. This project aims to understand ethnocultural food and health practices of Aboriginal and immigrant women, and how these intersect with respect to the legacy of Aboriginal colonialism and to the social contexts of cultural adaptation and adjustment of immigrants. The findings will inform the development of visual tools for health promotion by practitioners. Methods/Design This four-phase study employs a case study design allowing for multiple means of data collection and different units of analysis. Phase 1 consists of a scoping review of the literature. Phases 2 and 3 incorporate pictorial representations of food choices (photovoice in Phase 2) with semi-structured photo-elicited interviews (in Phase 3). The findings from Phases 1-3 and consultations with key stakeholders will generate key understandings for Phase 4, the production of culturally appropriate visual tools. For the scoping review, an emerging methodological framework will be utilized in addition to systematic review guidelines. A research librarian will assist with the search strategy and retrieval of literature. For Phases 2 and 3, recruitment of 20-24 women will be facilitated by team member affiliations at perinatal clinics in one of the city's most diverse neighbourhoods. The interviews will reveal culturally normative practices surrounding maternal food choices and consumption, including how women negotiate these practices within their own worldview and experiences. A structured and comprehensive integrated knowledge translation plan has been formulated. Discussion The findings of this study will provide practitioners with an understanding of the cultural differences that affect women's dietary choices during maternity. We expect that the developed resources will be of immediate use within the women's units and will enhance counseling efforts. Wide dissemination of outputs may have a greater long term impact in the primary and secondary prevention of these high risk conditions.

Physical activity counseling in primary health care in Brazil: a national study on prevalence and associated factors

Abstract Background The aim of this study was to determine the prevalence and correlates of physical activity counseling among physicians and nurses working in primary health care in Brazil. Methods A phone survey was carried out in 2011 with professionals working in primary health care in Brazil. The target sample consisted of 1,600 randomly selected primary care units covering all regions of the country. We successfully interviewed 529 professionals within the sampled units; 182 physicians and 347 nurses. The overall response rate was 49.6%. Multivariable logistic regression was used to estimate correlates of counseling in the whole sample and separately for physicians and nurses. Results The prevalence of regular physical activity counseling for at least six months was 68.9% (95% CI 64.9; 72.8) and was significantly higher among physicians compared to nurses (p < 0.05). Most professionals (93.2%) interviewed were unfamiliar with current physical activity recommendations for health. In the adjusted analysis, physical activity counseling was more frequent among those who report assessing patient’s physical activity (OR = 2.16; 95% CI 1.41; 3.29), those reporting that lack of time was not a barrier for counseling (OR = 0.62 95% CI 0.42-0.93), those who felt prepared to provide physical activity counseling (OR = 2.34; 95% CI 1.50-3.66), and those working at primary care units offering physical activity programs for patients (OR = 2.06; 95% CI 1.33-3.20). In the stratified analysis, only assessing patient’s physical activity was a significant correlate among physicians whereas assessing patient’s physical activity, feeling prepared to provide counseling and working in units with physical activity interventions were significant correlates among nurses. Conclusions Physicians and nurses deemed physical activity counseling of great importance in primary health care in Brazil. However, in order to increase the quality of counseling and the number of professionals engaging in this activity, these health teams require greater knowledge about physical activity (global recommendations for health) as well as training on the application of instruments for assessing physical activity. Moreover, sufficient time must be allowed during consultations for the counseling process, and physical activity promotion programs should be implemented within the primary health care units.

Accessibility and demand at an Emergency Care Unit: the user's perspective

AIM: To analyze the search for Emergency Care (EC) in the Western Health District of Ribeirão Preto (São Paulo), in order to identify the reasons why users turn to these services in situations that are not characterized as urgencies and emergencies. METHODS: A qualitative and descriptive study was undertaken. A guiding script was applied to 23 EC users, addressing questions related to health service accessibility and welcoming, problem solving, reason to visit the EC and care comprehensiveness. RESULTS: The subjects reported that, at the Primary Health Care services, receiving care and scheduling consultations took a long time and that the opening hours of these services coincide with their work hours. At the EC service, access to technologies and medicines was easier. CONCLUSION: Primary health care services have been unable to turn into the entry door to the health system, being replaced by emergency services, putting a significant strain on these services' capacity.

Stigma and higher rates of psychiatric re-hospitalization: São Paulo public mental health system

OBJECTIVE: The aim of this study was to assess re-hospitalization rates of individuals with psychosis and bipolar disorder and to study determinants of readmission. METHODS: Prospective observational study, conducted in São Paulo, Brazil. One hundred-sixty-nine individuals with bipolar and psychotic disorder in need of hospitalization in the public mental health system were followed for 12 months after discharge. Their families were contacted by telephone and interviews were conducted at 1, 2, 6 and 12 months post-discharge to evaluate readmission rates and factors related. RESULTSOne-year re-hospitalization rate was of 42.6%. Physical restraint during hospital stay was a risk factor (OR = 5.4-10.5) for readmission in most models. Not attending consultations after discharge was related to the 12-month point readmission (OR = 8.5, 95%CI 2.3-31.2) and to the survival model (OR = 3.2, 95%CI 1.5-7.2). Number of previous admissions was a risk factor for the survival model (OR = 6.6-11.9). Family's agreement with permanent hospitalization of individuals with mental illness was the predictor associated to readmission in all models (OR = 3.5-10.9) and resulted in shorter survival time to readmission; those readmitted were stereotyped as dangerous and unhealthy. CONCLUSIONS: Family's stigma towards mental illness might contribute to the increase in readmission rates of their relatives with psychiatric disorders. More studies should be conducted to depict mechanisms by which stigma increases re-hospitalization rates.

Factors associated with failure of clinical screening among blood donors who have altered serological results in the Centro Regional de Hemoterapia de Ribeirão Preto

OBJECTIVE: This study aimed to investigate the frequency of positive results for hepatitis B and C, HIV and syphilis in blood donations at the Centro Regional de Hemoterapia de Ribeirão Preto, to describe donors with positive results according to some demographic and socioeconomic variables, to identify risk factors associated to these donors and the reasons that they were not detected during clinical screening. METHODS: A descriptive study was performed between July 1st 2005 and July 31st 2006 by interviewing 106 donors after medical consultations where they were informed of positive results for hepatitis B, hepatitis C, HIV or syphilis. RESULTS: There was a predominance of first-time donors, males, under 50-year olds, married individuals, from Ribeirão Preto, with elementary education, low economic status and of people who donated at the request of friends or relatives. Hepatitis C was the most frequently detected infection (56.6%), followed by hepatitis B (20.7%), HIV (12.3%) and syphilis(10.4%). About 40% of donors had omitted risk factors for different reasons: because they trusted the results of serological tests, did not feel comfortable about talking of risk factors or did not consider them relevant. Other justifications were the duration of the interview, the interviewer was unskilled, embarrassment and doubts about confidentiality. CONCLUSION: The results indicate the need for changes in the approach to clinical screening and a review of methods to attract and guide potential donors.