Care cost for pregnant and parturient women with diabetes and mild hyperglycemia

OBJECTIVE: To compare inpatient and outpatient care costs for pregnant/parturient women with diabetes and mild hyperglycemia. METHODS: A prospective observational quantitative study was conducted in the Perinatal Diabetes Center in the city of Botucatu, Southeastern Brazil, between 2007 and 2008. Direct and indirect costs and disease-specific costs (medications and tests) were estimated. Thirty diet-treated pregnant women with diabetes were followed up on an outpatient basis, and 20 who required insulin therapy were hospitalized. RESULTS: The cost of diabetes disease (prenatal and delivery care) was US$ 3,311.84 for inpatients and US$ 1,366.04 for outpatients. CONCLUSIONS: Direct and indirect costs as well as total prenatal care cost were higher for diabetic inpatients while delivery care costs and delivery-postpartum hospitalization were similar. Prenatal and delivery-postpartum care costs were higher for these patients compared to those paid by Brazilian National Health System.

Payment for performance in the Family Health Programme: lessons from the UK Quality and Outcomes Framework

OBJECTIVE: Payment for performance financial incentive schemes reward doctors based on the quality and the outcomes of their treatment. In Brazil, the Ministry of Health is looking to scale up its use in public hospitals and some municipalities are developing payment for performance schemes even for the Family Health Programme. In this article the Quality and Outcomes Framework used in the UK since 2004 is discussed, as well as its experience to elaborate some important lessons that Brazilian municipalities should consider before embarking on payment for performance scheme in primary care settings.

Cut-off point for WHOQOL-bref as a measure of quality of life of older adults

OBJECTIVE To propose a cut-off for the World Health Organization Quality of Life-Bref (WHOQOL-bref) as a predictor of quality of life in older adults. METHODS Cross-sectional study with 391 older adults registered in the Northwest Health District in Belo Horizonte, MG, Southeastern Brazil, between October 8, 2010 and May 23, 2011. The older adults’ quality of life was measured using the WHOQOL-bref. The analysis was rationalized by outlining two extreme and simultaneous groups according to perceived quality of life and satisfaction with health (quality of life good/satisfactory – good or very good self-reported quality of life and being satisfied or very satisfied with health – G5; and poor/very poor quality of life – poor or very poor self-reported quality of life and feeling dissatisfied or very dissatisfied with health – G6). A Receiver-Operating Characteristic curve (ROC) was created to assess the diagnostic ability of different cut-off points of the WHOQOL-bref. RESULTS ROC curve analysis indicated a critical value 60 as the optimal cut-off point for assessing perceived quality of life and satisfaction with health. The area under the curve was 0.758, with a sensitivity of 76.8% and specificity of 63.8% for a cut-off of ≥ 60 for overall quality of life (G5) and sensitivity 95.0% and specificity of 54.4% for a cut-off of < 60 for overall quality of life (G6). CONCLUSIONS Diagnostic interpretation of the ROC curve revealed that cut-off < 60 for overall quality of life obtained excellent sensitivity and negative predictive value for tracking older adults with probable worse quality of life and dissatisfied with health.

Brazilian version of the Quality of Care Scale: the perspective of people with disabilities

OBJECTIVE To analyze evidence of the validity and reliability of a Brazilian Portuguese version of the Quality of Care Scale from the perspective of people with physical and intellectual disabilities.METHODS There were 162 people with physical disabilities and 156 with intellectual disabilities from Porto Alegre and metropolitan region, who participated in the study in 2008. Classical psychometrics was used to independently analyze the two samples. Hypotheses for evidence of criterion validity (concurrent type) were tested with the Mann-Whitney test for non-normal distributions. Principal components analysis was used to explore factorial models. Evidence of reliability was calculated with Cronbach alpha for the scales and subscales. Test-retest reliability was analyzed for individuals with intellectual disabilities through intra-class correlation coefficient and the Willcoxon test.RESULTS The principal components in the group with physical disabilities replicated the original model presented as a solution to the international project data. Evidence of discriminant validity and test-retest reliability was found.CONCLUSIONS The transcultural factor model found within the international sample project seems appropriate for the samples investigated in this study, especially the physical disabilities group. Depression, pain, satisfaction with life and disability may play a mediating role in the evaluation of quality of care. Additional research is needed to add to evidence of the validity of the instruments.

Association between sleep quality and quality of life in nursing professionals working rotating shifts

OBJECTIVE To analyze the association between sleep quality and quality of life of nursing professionals according to their work schedules.METHODS A prospective, cross-sectional, observational study was conducted between January and December 2010, with 264 nursing professionals, drawn from 989 subjects at Botucatu General Hospital and stratified by professional category. The Pittsburg Sleep Quality Index and the WHOQOL-bref were administered to evaluate sleep quality and quality of life, respectively. Self-reported demographic data were collected with a standard form. Continuous variables were reported as means and standard deviations, and categorical variables were expressed as proportions. Associations were evaluated using Spearman’s correlation coefficient. The association of night-shift work and gender with sleep disturbance was evaluated by logistic regression analysis using a model adjusted for age and considering sleep disturbance the dependent variable. The level of significance was p < 0.05.RESULTS Night-shift work was associated with severe worsening of at least one component of sleep quality in the model adjusted for age (OR = 1.91; 95%CI 1.04;3.50; p = 0.036). Female gender was associated with sleep disturbance (OR = 3.40; 95%CI 1.37;8.40; p = 0.008). Quality of life and quality of sleep were closely correlated (R = -0.56; p < 0.001).CONCLUSIONS Characteristics of the nursing profession affect sleep quality and quality of life, and these two variables are associated.

Evaluation of maternal and neonatal hospital care: quality index of completeness

OBJECTIVE Develop an index to evaluate the maternal and neonatal hospital care of the Brazilian Unified Health System.METHODS This descriptive cross-sectional study of national scope was based on the structure-process-outcome framework proposed by Donabedian and on comprehensive health care. Data from the Hospital Information System and the National Registry of Health Establishments were used. The maternal and neonatal network of Brazilian Unified Health System consisted of 3,400 hospitals that performed at least 12 deliveries in 2009 or whose number of deliveries represented 10.0% or more of the total admissions in 2009. Relevance and reliability were defined as criteria for the selection of variables. Simple and composite indicators and the index of completeness were constructed and evaluated, and the distribution of maternal and neonatal hospital care was assessed in different regions of the country.RESULTS A total of 40 variables were selected, from which 27 single indicators, five composite indicators, and the index of completeness of care were built. Composite indicators were constructed by grouping simple indicators and included the following variables: hospital size, level of complexity, delivery care practice, recommended hospital practice, and epidemiological practice. The index of completeness of care grouped the five variables and classified them in ascending order, thereby yielding five levels of completeness of maternal and neonatal hospital care: very low, low, intermediate, high, and very high. The hospital network was predominantly of small size and low complexity, with inadequate child delivery care and poor development of recommended and epidemiological practices. The index showed that more than 80.0% hospitals had a low index of completeness of care and that most qualified heath care services were concentrated in the more developed regions of the country.CONCLUSIONS The index of completeness proved to be of great value for monitoring the maternal and neonatal hospital care of Brazilian Unified Health System and indicated that the quality of health care was unsatisfactory. However, its application does not replace specific evaluations.

Socioeconomic inequalities in the access to and quality of health care services

OBJECTIVE To assess the inequalities in access, utilization, and quality of health care services according to the socioeconomic status. METHODS This population-based cross-sectional study evaluated 2,927 individuals aged ≥ 20 years living in Pelotas, RS, Southern Brazil, in 2012. The associations between socioeconomic indicators and the following outcomes were evaluated: lack of access to health services, utilization of services, waiting period (in days) for assistance, and waiting time (in hours) in lines. We used Poisson regression for the crude and adjusted analyses. RESULTS The lack of access to health services was reported by 6.5% of the individuals who sought health care. The prevalence of use of health care services in the 30 days prior to the interview was 29.3%. Of these, 26.4% waited five days or more to receive care and 32.1% waited at least an hour in lines. Approximately 50.0% of the health care services were funded through the Unified Health System. The use of health care services was similar across socioeconomic groups. The lack of access to health care services and waiting time in lines were higher among individuals of lower economic status, even after adjusting for health care needs. The waiting period to receive care was higher among those with higher socioeconomic status. CONCLUSIONS Although no differences were observed in the use of health care services across socioeconomic groups, inequalities were evident in the access to and quality of these services.

Economic analysis of surgical treatment of hip fracture in older adults

OBJECTIVE To analyze the incremental cost-utility ratio for the surgical treatment of hip fracture in older patients.METHODS This was a retrospective cohort study of a systematic sample of patients who underwent surgery for hip fracture at a central hospital of a macro-region in the state of Minas Gerais, Southeastern Brazil between January 1, 2009 and December 31, 2011. A decision tree creation was analyzed considering the direct medical costs. The study followed the healthcare provider’s perspective and had a one-year time horizon. Effectiveness was measured by the time elapsed between trauma and surgery after dividing the patients into early and late surgery groups. The utility was obtained in a cross-sectional and indirect manner using the EuroQOL 5 Dimensions generic questionnaire transformed into cardinal numbers using the national regulations established by the Center for the Development and Regional Planning of the State of Minas Gerais. The sample included 110 patients, 27 of whom were allocated in the early surgery group and 83 in the late surgery group. The groups were stratified by age, gender, type of fracture, type of surgery, and anesthetic risk.RESULTS The direct medical cost presented a statistically significant increase among patients in the late surgery group (p < 0.005), mainly because of ward costs (p < 0.001). In-hospital mortality was higher in the late surgery group (7.4% versus 16.9%). The decision tree demonstrated the dominance of the early surgery strategy over the late surgery strategy: R$9,854.34 (USD4,387.17) versus R$26,754.56 (USD11,911.03) per quality-adjusted life year. The sensitivity test with extreme values proved the robustness of the results.CONCLUSIONS After controlling for confounding variables, the strategy of early surgery for hip fracture in the older adults was proven to be dominant, because it presented a lower cost and better results than late surgery.

Cyclosporine versus tacrolimus: cost-effectiveness analysis for renal transplantation in Brazil

OBJECTIVE To analyze the cost-effectiveness of treatment regimens with cyclosporine or tacrolimus, five years after renal transplantation.METHODS This cost-effectiveness analysis was based on historical cohort data obtained between 2000 and 2004 and involved 2,022 patients treated with cyclosporine or tacrolimus, matched 1:1 for gender, age, and type and year of transplantation. Graft survival and the direct costs of medical care obtained from the National Health System (SUS) databases were used as outcome results.RESULTS Most of the patients were women, with a mean age of 36.6 years. The most frequent diagnosis of chronic renal failure was glomerulonephritis/nephritis (27.7%). In five years, the tacrolimus group had an average life expectancy gain of 3.96 years at an annual cost of R$78,360.57 compared with the cyclosporine group with a gain of 4.05 years and an annual cost of R$61,350.44.CONCLUSIONS After matching, the study indicated better survival of patients treated with regimens using tacrolimus. However, regimens containing cyclosporine were more cost-effective.

Alterations in psychosocial health of people affected by asbestos poisoning

OBJECTIVE To analyze the state of psychosocial and mental health of professionals affected by asbestos.METHODS A cross-sectional study was conducted with 110 professionals working in the Ferrolterra region of Spain, who were affected by asbestos poisoning. This group was compared with a group of 70 shipyard workers with no manifestation of work-related diseases. All the participants were male with a mean age of 67 years. This study was conducted in 2013, between January and June, and used the SCL-90 questionnaire by Derogatis as its primary measure for research. This questionnaire consists of 9 variables that measure psychosomatic symptoms. In addition, an overall index of psychosomatic gravity was calculated. The participants were also asked two questions concerning their overall perception of feeling good. Data were analyzed by ANOVA and logistic regression.RESULTS Participants affected by asbestos poisoning showed high occurrence rates of psychological health variables such as somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism, and global severity index.CONCLUSIONS Social interaction as a differentiating factor between workers affected by work-related chronic syndromes as compared to healthy participants will possibly aid in the development of intervention programs by improving the social network of affected individuals.

Religiousness and health-related quality of life of older adults

OBJECTIVE To examine whether religiousness mediates the relationship between sociodemographic factors, multimorbidity and health-related quality of life of older adults.METHODS This population-based cross-sectional study is part of the Survey on Health, Well-Being, and Aging (SABE). The sample was composed by 911 older adults from Sao Paulo, SP, Southeastern Brazil. Structural equation modeling was performed to assess the mediator effect of religiousness on the relationship between selected variables and health-related quality of life of older adults, with models for men and women. The independent variables were: age, education, family functioning and multimorbidity. The outcome variable was health-related quality of life of older adults, measured by SF-12 (physical and mental components). The mediator variables were organizational, non-organizational and intrinsic religiousness. Cronbach’s alpha values were: physical component = 0.85; mental component = 0.80; intrinsic religiousness = 0.89 and family APGAR (Adaptability, Partnership, Growth, Affection, and Resolve) = 0.91.RESULTS Higher levels of organizational and intrinsic religiousness were associated with better physical and mental components. Higher education, better family functioning and fewer diseases contributed directly to improved performance in physical and mental components, regardless of religiousness. For women, organizational religiousness mediated the relationship between age and physical (β = 2.401, p < 0.01) and mental (β = 1.663, p < 0.01) components. For men, intrinsic religiousness mediated the relationship between education and mental component (β = 7.158, p < 0.01).CONCLUSIONS Organizational and intrinsic religiousness had a beneficial effect on the relationship between age, education and health-related quality of life of these older adults.

Intra-hospital organ and tissue donation coordination project: cost-effectiveness and social benefits

OBJECTIVE To evaluate the viability of a professional specialist in intra-hospital committees of organ and tissue donation for transplantation. METHODS Epidemiological, retrospective and cross-sectional study (2003-2011 and 2008-2012), which was performed using organ donation for transplants data in the state of Sao Paulo, Southeastern Brazil. Nine hospitals were evaluated (hospitals 1 to 9). Logistic regression was used to evaluate the differences in the number of brain death referrals and actual donors (dependent variables) after the professional specialist started work (independent variable) at the intra-hospital committee of organ and tissue donation for transplantation. To evaluate the hospital invoicing, the hourly wage of the doctor and registered nurse, according to the legislation of the Consolidation of Labor Laws, were calculated, as were the investment return and the time elapsed to do so. RESULTS Following the nursing specialist commencement on the committee, brain death referrals and the number of actual donors increased at hospital 2 (4.17 and 1.52, respectively). At hospital 7, the number of actual donors also increased from 0.005 to 1.54. In addition, after the nurse started working, hospital revenues increased by 190.0% (ranging 40.0% to 1.955%). The monthly cost for the nurse working 20 hours was US$397.97 while the doctor would cost US$3,526.67. The return on investment was 275% over the short term (0.36 years). CONCLUSIONS This paper showed that including a professional specialist in intra-hospital committees for organ and tissue donation for transplantation proved to be cost-effective. Further economic research in the area could contribute to the efficient public policy implementation of this organ and tissue harvesting model.

A low cost method to produce a gaseous environment for the isolation of Helicobacter pylori

A low cost method (LCM) to produce a gaseous environment for the isolation of Helicobacter pylori, was compared with the standard Gas Park system. The LCM uses a carbonated antacid tablet, a plastic bag with tap water, a candle, and a wide-mouthed glass jar provided with a tight-fitting metalic screw cap and a rubber gasket. Antral gastric biopsies from 153 cases were incubated by duplicate on blood agar plates and treated with the two methods. In 95 cases the agent was isolated from both, and only from the standard method in 10 cases; the opposite condition was found in five cases, and 43 were negative. That difference is not significant (Pearson's X²= 93.25 p > 0,05)