Hypertension and clustering of cardiovascular risk factors in a community in Southeast Brazil: the Bambuí Health and Ageing Study

OBJECTIVE - A population-based prospective study was analysed to: a) determine the prevalence of hypertension; b) investigate the clustering of other cardiovascular risk factors and c) verify whether older differed from younger adults in the pattern of clustering. METHODS - The data comprised a representative sample of the population of Bambuí, Brazil. Multiple logistic regression was used to investigate the independent association between hypertension and selected factors. RESULTS - A total of 820 younger adults (82.5%) and 1494 older adults (85.9%) participated in this study. The overall prevalence of hypertension was 24.8% (SE=1.4 %), being higher in women (26.9±1.5%) than in men (22.0± 1.7%) (p=0.033). Hypertension was positively and significantly associated with physical inactivity, overweight, hypercholesterolemia hyperglycemia and hypertriglyceridemia. The coexistence of hypertension with 4 or more of these risk factors occurred 6 times more than expected by chance, after adjusting for age and sex (OR=6.3; 95%CI: 3.4-11.9). The pattern of risk factor clustering in hypertensive individuals differed with age. CONCLUSION - Our results reinforce the need to increase detection and treatment of hypertension and to approach patients' global risk profiles.

Assessment of the techniques of blood pressure measurement by health professionals

OBJECTIVE: To assess blood pressure measurement by health professionals of a public hospital in São Paulo State. METHODS: Semi-structured interviews and direct observation were performed with a verification list according to the criteria reported by Perloff et al. One hundred and five health professionals took part in the study. After measuring blood pressure, the level of concordance between the way the procedure was performed and the recommended one was assessed. RESULTS: Nurses and nurse's aides abided by 40% of the recommended procedures for adequate blood pressure measurement. The other categories of health professionals (nursing and medicine teachers, physicians, residents, and nursing students) abided by approximately 70%. CONCLUSION: Permanent educational activities aiming at standardizing blood pressure measurement should be implemented among the different categories of health professionals.

Impact of nutritional counseling in reducing serum cholesterol in public health service patients

OBJECTIVE: To assess the impact of nutritional attention on the lipid profile and nutritional status of hypercholesterolemic patients attended in health centers of Belo Horizonte. METHODS: Using nutritional attendance patient record cards from two health units, the evolution of the lipid profile and the nutritional state (BMI) was monitored of 96 hypercholesterolemic patients who received diet. The patients were appraised at the following moments: initial (1st consultation), after 3 months (2nd consultation) and last consultation (variable for each patient). RESULTS: On the first attendance, 44,4% of the patients presented not only high total cholesterol and LDL-c, but also hypertriglyceridemia and 70.3% were overweight or obese, but most patients (75.6%) presented adequate HDL-c levels. There was significant reduction in the BMI, total cholesterol, LDL-c values (p < 0.01) and also in the triglyceride levels (p < 0.05) in the first three months, without alteration in the HDL-c levels. A significant reduction (p < 0.01) was observed in the frequency of individuals with high cholesterol (from 89.6% down to 47.9%), high and very high LDL-c (from 82.6% down to 45.7%), as well as high and very high triglyceride (from 43.6% down to 16.7%). The observed reduction in frequency of the low HDL-c was statistically meaningless. CONCLUSION: This study evidences the effect of the nutritional attention on lipid profile in hypercholesterolemic patients, reinforcing the need for a multiprofessional team to attend them at the public health services.

Fibrilação atrial e demência: resultados do São Paulo ageing & health study

FUNDAMENTO: A fibrilação atrial é um fator de risco controverso para demência. OBJETIVO: O objetivo deste estudo é avaliar a associação entre fibrilação atrial e demência em participantes do São Paulo Ageing & Health. MÉTODOS: O São Paulo Ageing & Health é um estudo transversal, de base populacional, de idosos residentes em um uma região de baixa renda da cidade de São Paulo, Brasil. Diagnóstico de demência foi realizado de acordo com o protocolo do grupo 10/66, com base em critérios do Manual de Diagnóstico e Estatística das Perturbações Mentais (DSM-IV). O diagnóstico de fibrilação atrial foi feito por eletrocardiograma de 12 derivações, avaliado por dois cardiologistas. Dados demográficos e de fatores de risco cardiovasculares também foram obtidos. RESULTADOS: A demência foi diagnosticada em 66 (4,3%) e fibrilação atrial em 36 (2,4%) de 1.524 participantes com um eletrocardiograma válido. A razão de chances bruta para demência em participantes com fibrilação atrial foi 2,8 (intervalo de confiança [IC] 95%: 1,0-8,1; p = 0,06) em comparação com indivíduos sem fibrilação atrial. Relação positiva foi encontrada em mulheres (RC 4,2; IC 95%: 1,2-15,1; p = 0,03). Após ajuste para idade, no entanto, essa associação tornou-se não significativa (RC 2,2, IC 95%: 0,6-8,9; p = 0,26). CONCLUSÃO: Não houve associação independente entre a fibrilação atrial e demência nessa amostra. A prevalência da fibrilação atrial pode ser baixa nesta população em virtude da mortalidade cardiovascular prematura.

Investigation Route of the Coronary Patient in the Public Health System in Curitiba, São Paulo and in Incor - IMPACT Study

Background: The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization. Objective: To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP. Methods: Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies. Results: There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure. Conclusion: Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS.

Comparison of Cardiovascular Risk Factors in Different Areas of Health Care Over a 20-Year Period

Background:Cardiovascular diseases (CVDs) are the leading cause of death worldwide. Knowledge about cardiovascular risk factors (CVRFs) in young adults and their modification over time are measures that change the risks and prevent CVDs.Objectives:To determine the presence of CVRFs and their changes in different health care professionals over a period of 20 years.Methods:All students of medicine, nursing, nutrition, odontology, and pharmacy departments of Federal University of Goiás who agreed to participate in this study were evaluated when they started their degree courses and 20 years afterward. Questionnaires on CVRFs [systemic arterial hypertension (SAH), diabetes mellitus, dyslipidemia, and family history of early CVD, smoking, alcohol consumption, and sedentarism] were administered. Cholesterol levels, blood sugar levels, blood pressure, weight, height, and body mass index were determined. The Kolmogorov-Smirnov test was used to evaluate distribution, the chi-square test was used to compare different courses and sexes, and the McNemar test was used for comparing CVRFs. The significance level was set at a p value of < 0.05.Results:The first stage of the study included 281 individuals (91% of all the students), of which 62.9% were women; the mean age was 19.7 years. In the second stage, 215 subjects were reassessed (76% of the initial sample), of which 59.07% were women; the mean age was 39.8 years. The sample mostly consisted of medical students (with a predominance of men), followed by nursing, nutrition, and pharmacy students, with a predominance of women (p < 0.05). Excessive weight gain, SAH, and dyslipidemia were observed among physicians and dentists (p < 0.05). Excessive weight gain and SAH and a reduction in sedentarism (p < 0.05) were observed among pharmacists. Among nurses there was an increase in excessive weight and alcohol consumption (p < 0.05). Finally, nutritionists showed an increase in dyslipidemia (p < 0.05).Conclusion:In general, there was an unfavorable progression of CVRFs in the population under study, despite it having adequate specialized knowledge about these risk factors.

Cost-Effectiveness of High, Moderate and Low-Dose Statins in the Prevention of Vascular Events in the Brazilian Public Health System

Background:Statins have proven efficacy in the reduction of cardiovascular events, but the financial impact of its widespread use can be substantial.Objective:To conduct a cost-effectiveness analysis of three statin dosing schemes in the Brazilian Unified National Health System (SUS) perspective.Methods:We developed a Markov model to evaluate the incremental cost-effectiveness ratios (ICERs) of low, intermediate and high intensity dose regimens in secondary and four primary scenarios (5%, 10%, 15% and 20% ten-year risk) of prevention of cardiovascular events. Regimens with expected low-density lipoprotein cholesterol reduction below 30% (e.g. simvastatin 10mg) were considered as low dose; between 30-40%, (atorvastatin 10mg, simvastatin 40mg), intermediate dose; and above 40% (atorvastatin 20-80mg, rosuvastatin 20mg), high-dose statins. Effectiveness data were obtained from a systematic review with 136,000 patients. National data were used to estimate utilities and costs (expressed as International Dollars - Int$). A willingness-to-pay (WTP) threshold equal to the Brazilian gross domestic product per capita (circa Int$11,770) was applied.Results:Low dose was dominated by extension in the primary prevention scenarios. In the five scenarios, the ICER of intermediate dose was below Int$10,000 per QALY. The ICER of the high versus intermediate dose comparison was above Int$27,000 per QALY in all scenarios. In the cost-effectiveness acceptability curves, intermediate dose had a probability above 50% of being cost-effective with ICERs between Int$ 9,000-20,000 per QALY in all scenarios.Conclusions:Considering a reasonable WTP threshold, intermediate dose statin therapy is economically attractive, and should be a priority intervention in prevention of cardiovascular events in Brazil.

Cardiac Surgery Costs According to the Preoperative Risk in the Brazilian Public Health System

AbstractBackground:Heart surgery has developed with increasing patient complexity.Objective:To assess the use of resources and real costs stratified by risk factors of patients submitted to surgical cardiac procedures and to compare them with the values reimbursed by the Brazilian Unified Health System (SUS).Method:All cardiac surgery procedures performed between January and July 2013 in a tertiary referral center were analyzed. Demographic and clinical data allowed the calculation of the value reimbursed by the Brazilian SUS. Patients were stratified as low, intermediate and high-risk categories according to the EuroSCORE. Clinical outcomes, use of resources and costs (real costs versus SUS) were compared between established risk groups.Results:Postoperative mortality rates of low, intermediate and high-risk EuroSCORE risk strata showed a significant linear positive correlation (EuroSCORE: 3.8%, 10%, and 25%; p < 0.0001), as well as occurrence of any postoperative complication EuroSCORE: 13.7%, 20.7%, and 30.8%, respectively; p = 0.006). Accordingly, length-of-stay increased from 20.9 days to 24.8 and 29.2 days (p < 0.001). The real cost was parallel to increased resource use according to EuroSCORE risk strata (R$ 27.116,00 ± R$ 13.928,00 versus R$ 34.854,00 ± R$ 27.814,00 versus R$ 43.234,00 ± R$ 26.009,00, respectively; p < 0.001). SUS reimbursement also increased (R$ 14.306,00 ± R$ 4.571,00 versus R$ 16.217,00 ± R$ 7.298,00 versus R$ 19.548,00 ± R$935,00; p < 0.001). However, as the EuroSCORE increased, there was significant difference (p < 0.0001) between the real cost increasing slope and the SUS reimbursement elevation per EuroSCORE risk strata.Conclusion:Higher EuroSCORE was related to higher postoperative mortality, complications, length of stay, and costs. Although SUS reimbursement increased according to risk, it was not proportional to real costs.

Acute Coronary Syndrome Treatment Costs from the Perspective of the Supplementary Health System

AbstractBackground:Acute coronary syndrome (ACS) is defined as a “group of clinical symptoms compatible with acute myocardial ischemia”, representing the leading cause of death worldwide, with a high clinical and financial impact. In this sense, the development of economic studies assessing the costs related to the treatment of ACS should be considered.Objective:To evaluate costs and length of hospital stay between groups of patients treated for ACS undergoing angioplasty with or without stent implantation (stent+ / stent-), coronary artery bypass surgery (CABG) and treated only clinically (Clinical) from the perspective of the Brazilian Supplementary Health System (SHS).Methods:A retrospective analysis of medical claims of beneficiaries of health plans was performed considering hospitalization costs and length of hospital stay for management of patients undergoing different types of treatment for ACS, between Jan/2010 and Jun/2012.Results:The average costs per patient were R$ 18,261.77, R$ 30,611.07, R$ 37,454.94 and R$ 40,883.37 in the following groups: Clinical, stent-, stent+ and CABG, respectively. The average costs per day of hospitalization were R$ 1,987.03, R$ 4,024.72, R$ 6,033.40 and R$ 2,663.82, respectively. The average results for length of stay were 9.19 days, 7.61 days, 6.19 days and 15.20 days in these same groups. The differences were significant between all groups except Clinical and stent- and between stent + and CABG groups for cost analysis.Conclusion:Hospitalization costs of SCA are high in the Brazilian SHS, being significantly higher when interventional procedures are required.

Health education for children in the control of Schistosomasis

Health education for children is an important measure in the control of schistosomiasis especially considering the characteristics of the disease during childhood, such as high prevalence, high percent of treatment resistance, high rates of egg elimination and high level of reinfection, as reported in studies conducted in endemic areas. All of these facts indicate that children play a role in the maintenance and transmission of schistosomiasis. Historically in Brazil, Health Education concerning the major Brazilian endemies consists of a kind of vertical, interventionist and temporary action. An alternative would be to create a permanent health education process by assigning health education teachers to elementary schools. This would require expansion and improvement of teacher training and the development of programs taking into account: 1) the cognitive aspects of the child, the child's perception of reality and of the health/illness process; 2) the adaptation of instruction means and materials to the age group; 3) a "pedagogy of liberation" approach emphasizing the possibility of transforming life conditions since schistosomiasis is related to the lack of public services such as basic sanitation and clean domestic water supply.

Health education, public information, and communication in schistosomiasis control in Brazil: a brief retrospective and perspectives

In recent years, the strategy for the control of schistosomiasis has placed increased emphasis on the role of health education, public information, and communication. This should, not only bring about specific changes in behavior aiming at disease prevention, but also stimulate participation of the community in health programs. Beyond this, it is desirable that both community members and researchers should seek better life conditions through a transformative social action. The present paper addresses these concerns; first, by critically reviewing some health education programs that were developed in Brazil, and, secondly, by analyzing and suggesting ways to improve this area.

Schistosomiasis control in a primary health care system

The successful implementation of a Primary Health Care System (PHC) in any country depends primarily on the ability to adapt its concepts and principles to the country's culture and development stage. Thus, the PHC system should reflect a balanced interaction between available resources, such as health manpower capabilities, and the nature and magnitude of the health problems. In addition, PHC should be viewed as the inlet to a multi-level pyramidal health system which caters to both community and individual needs in a balanced way. The adage that Ministries of Health should "work with and for the people" in health development, is especially true in the area of PHC, and hence, the health policy should aim to integrate health services in community development and involve people in its planning, implementation and evaluation.

An interactive perspective of health education for the tropical disease control: the schistosomiasis case

Some municipalities in Brazil have been requesting orientation for the implementation of health education programs related to the control of schistosomiasis. This demand was based on experiences in the development of health education researches, strategies and materials for school-age children, involving the communities and secretaries of health and education. Motivated by this request and the recently implemented plan of health services (Unified Health System - Sistema Único de Saúde - SUS) that gives autonomy to the municipalities to utilize health resources and services in Brazil, this paper presents an interactive perspective of planning health education research and programs. The purpose of this perspective is to stimulate a reflection on the needs and actions of institutions and people involved in health education research and/or programs to obtain sustainability, commitment and effectiveness - not only in the control of schistosomiasis, but also in the improvement of environmental conditions, quality of life and personal health. This perspective comprises interaction among three levels related to health education programs: the decision level, the executive level and the beneficiary level. The needs and lines of action at each of these levels are discussed, as well as the ways in which they can interact with each other. This proposal may lead to useful interactive ways of planing, organizing, executing and evaluating health education research and/or program, not only towards the prevention and control of the disease at stake, but also to promote health in general.