Análise Envoltória de Dados na avaliação de hospitais públicos nas capitais brasileiras

OBJETIVO: Aplicar a metodologia de Análise Envoltória de Dados na avaliação do desempenho de hospitais públicos em termos das internações em suas clínicas médicas. MÉTODOS: A eficiência dos hospitais foi medida a partir do desempenho de unidades de decisão nas variáveis estudadas para cada hospital, no ano 2000. Foram analisados dados referentes às internações em clínica médica dos hospitais SUS das capitais estaduais do Brasil e Distrito Federal (taxas de mortalidade e tempo médio de internação, valor médio da internação e perfil de doenças). A técnica de análise de correlação canônica foi introduzida na restrição do intervalo de variação das variáveis. O modelo Constant Returns to Scale foi utilizado para gerar escores que permitissem avaliar a eficiência das unidades. A partir dos escores obtidos, os municípios foram classificados de acordo com seu desempenho relativo nas variáveis analisadas. Procurou-se correlação entre os escores de classificação com variáveis exógenas: despesas com programas de saúde básica por habitante e índice de desenvolvimento humano das capitais. RESULTADOS: Nos hospitais estudados se destacaram as doenças do aparelho circulatório (23,6% das internações); e a taxa de mortalidade foi de 10,3% das internações. Das 27 capitais, quatro alcançaram 100% de eficiência (Palmas, Macapá, Teresina e Goiânia), sete ficaram entre 85% e 100%, dez entre 70% e 85% e dez com menos de 70%. CONCLUSÕES: A ferramenta utilizada mostrou ser aplicável para a avaliação de desempenho de hospitais públicos, revelando a grande variabilidade entre as capitais brasileiras, no que se refere às internações em clínica médica.

Dynamic network data envelopment analysis for university hospitals evaluation

ABSTRACT OBJECTIVE To develop an assessment tool to evaluate the efficiency of federal university general hospitals. METHODS Data envelopment analysis, a linear programming technique, creates a best practice frontier by comparing observed production given the amount of resources used. The model is output-oriented and considers variable returns to scale. Network data envelopment analysis considers link variables belonging to more than one dimension (in the model, medical residents, adjusted admissions, and research projects). Dynamic network data envelopment analysis uses carry-over variables (in the model, financing budget) to analyze frontier shift in subsequent years. Data were gathered from the information system of the Brazilian Ministry of Education (MEC), 2010-2013. RESULTS The mean scores for health care, teaching and research over the period were 58.0%, 86.0%, and 61.0%, respectively. In 2012, the best performance year, for all units to reach the frontier it would be necessary to have a mean increase of 65.0% in outpatient visits; 34.0% in admissions; 12.0% in undergraduate students; 13.0% in multi-professional residents; 48.0% in graduate students; 7.0% in research projects; besides a decrease of 9.0% in medical residents. In the same year, an increase of 0.9% in financing budget would be necessary to improve the care output frontier. In the dynamic evaluation, there was progress in teaching efficiency, oscillation in medical care and no variation in research. CONCLUSIONS The proposed model generates public health planning and programming parameters by estimating efficiency scores and making projections to reach the best practice frontier.

Successful scale-up of human embryonic stem cell production in a stirred microcarrier culture system

Future clinical applications of human embryonic stem (hES) cells will require high-yield culture protocols. Currently, hES cells are mainly cultured in static tissue plates, which offer a limited surface and require repeated sub-culturing. Here we describe a stirred system with commercial dextran-based microcarriers coated with denatured collagen to scale-up hES cell production. Maintenance of pluripotency in the microcarrier-based stirred system was shown by immunocytochemical and flow cytometry analyses for pluripotency-associated markers. The formation of cavitated embryoid bodies expressing markers of endoderm, ectoderm and mesoderm was further evidence of maintenance of differentiation capability. Cell yield per volume of medium spent was more than 2-fold higher than in static plates, resulting in a significant decrease in cultivation costs. A total of 10(8) karyotypically stable hES cells were obtained from a unitary small vessel that needed virtually no manipulation during cell proliferation, decreasing risks of contamination. Spinner flasks are available up to working volumes in the range of several liters. If desired, samples from the homogenous suspension can be withdrawn to allow process validation needed in the last expansion steps prior to transplantation. Especially when thinking about clinical trials involving from dozens to hundreds of patients, the use of a small number of larger spinners instead of hundreds of plates or flasks will be beneficial. To our knowledge, this is the first description of successful scale-up of feeder- and Matrigel™-free production of undifferentiated hES cells under continuous agitation, which makes this system a promising alternative for both therapy and research needs.

Brazilian WHOQOL-OLD Module version: a Rasch analysis of a new instrument

OBJECTIVE: To evaluate the Brazilian version of WHOQOL-OLD Module and to test potential changes to the instrument to increase its psychometric adequacy. METHODS: A total of 424 older adults living in a city in Southern Brazil completed the WHOQOL-OLD instrument, in 2005. Rasch analysis was used to explore the psychometric performance of the scale, as implemented by the RUMM2020 software. Item-trait interaction, threshold disorders, presence of differential item functioning and item fit, were analyzed. RESULTS: Two ("death and dying" and "sensory abilities") out of six domains showed inadequate item-trait interactions. Rescoring the response scale and deleting the most misperforming items led to scale improvement. The evaluation of domains and items individually showed that the "intimacy" domain does perform well in contrast to the findings using the classical approach. In addition, the "sensory abilities" domain does not derive an interval measure in its current format. CONCLUSIONS: Unidimensionality and local independence were seen in all domains. Changes in the response scale and deletion of problematic items improved the scale's performance.

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.

A moderate decrease in temperature inhibits the calcium signaling mechanism(s) of the regulatory volume decrease in chick embryo cardiomyocytes

Chick cardiomyocytes, when submitted to hyposmotic swelling, exhibit a partial regulatory volume decrease (RVD). A Ca2+ influx by stretch-activated channels signals a taurine efflux and the RVD at 37°C. We evaluated the cell's performance at room temperature. Cardiomyocytes isolated and cultured from 11-day-old chick embryos were submitted to a hyposmotic solution (180 mOsm/kg H2O) at 37°C and at room temperature (26°C). Under these conditions we measured the changes in cell volume as well as the intracellular free Ca2+ (using fura-2). During hyposmotic swelling, cells at 37°C displayed a peak relative volume of 1.61 ± 0.03 and recovery to 1.22 ± 0.04 (N = 14), while cells at 26°C presented a peak swell relative volume of 1.74 ± 0.06 and did not recover (1.59 ± 0.09, N = 9). Transient increases in intracellular Ca2+, which are characteristic of the normal RVD, were observed at both temperatures (29.1 ± 4.5% (N = 8) and 115.2 ± 42.8% (N = 5) increase at 37° and 26°C (P<0.05), respectively). A delay in the Ca2+ transient increase was also observed when the cells were at 26°C (109 ± 34 s compared to 38 ± 9 s at 37°C, P<0.05). At room temperature the RVD does not occur because the calcium transient increase, which is an early event in the signaling of the RVD, is delayed. Also, free calcium is not cleared as in the 37°C RVD. In the normal RVD the free calcium returns to baseline levels. The very high and persistent free calcium levels seen at room temperature can lead to unregulated enzyme activities and may promote irreversible injury and cell death.

Estimando o retorno à educação do Brasil considerando a legislação educacional brasileira como um instrumento

Estimating the return to education the Brazilian legislation of education as an instrument considering. This paper aims to estimate the impact of education on wages in Brazil. GDP, Population, and the number of schools in the state and year when the individual was born as instruments for his education level were used. In this context, the paper consider other instrument, the Brazilian education Law 5692 of 1971. The results show that the Law 5692 of 1971 and the number of schools in the individual's year of birth bears a positive relationship with his education, and the returns to education decrease quite substantially when the method of instrumental variables is used.

Perspectivas das negociações entre o Mercosul e a União Europeia em um contexto de paralisia do sistema multilateral e da nova geografia econômica global

The aim of this paper is to scale the impact of changes in the patterns of international trade and Foreign Investment and how the shift in the world economic geography affects the relations between Mercosur and the European Union. The perception is that the outcome of negotiations between the two blocks is linked to the paralysis of the multilateral system and the European perspective of the economic dimension of the Agreement. The study suggests that the European Union faces conceptual and operational problems to establish clear goals and business strategies towards Mercosur and to insert them under a new global economic geography.