Risk factors for inadequate prenatal care use in the metropolitan area of Aracaju, Northeast Brazil

Abstract Background The aim of prenatal care is to promote good maternal and foetal health and to identify risk factors for adverse pregnancy outcomes in an attempt to promptly manage and solve them. Although high prenatal care attendance is reported in most areas in Brazil, perinatal and neonatal mortalities are disproportionally high, raising doubts about the quality and performance of the care provided. The objective of the present study was to evaluate the adequacy of prenatal care use and the risk factors involved in inadequate prenatal care utilization in the metropolitan area of Aracaju, Northeast Brazil. Methods A survey was carried out with puerperal women who delivered singleton liveborns in all four maternity hospitals of Aracaju. A total of 4552 singleton liveborns were studied. The Adequacy of Prenatal Care Utilization Index, modified according to the guidelines of the Prenatal Care and Birth Humanization Programme, was applied. Socioeconomic, demographic, biological, life style and health service factors were evaluated by multiple logistic regression. Results: Prenatal care coverage in Aracaju was high (98.3%), with a mean number of 6.24 visits. Prenatal care was considered to be adequate or intensive in 66.1% of cases, while 33.9% were considered to have inadequate usage. Age < 18 to 34 years at delivery, low maternal schooling, low family income, two or more previous deliveries, maternal smoking during pregnancy, having no partner and prenatal care obtained outside Aracaju were associated with inadequate prenatal care use. In contrast, private service attendance protected from inadequate prenatal care use. Conclusion Prenatal care coverage was high. However, a significant number of women still had inadequate prenatal care use. Socioeconomic inequalities, demographic factors and behavioural risk factors are still important factors associated with inadequate prenatal care use.

Nursing care time in the Intensive Care Unit: evaluation of the parameters proposed in COFEN Resolution Nº 293/04

This study aimed to evaluate the parameters established in COFEN Resolution 293/04 concerning nursing staff dimensioning in adult intensive care units (AICU). The research was conducted in six hospitals in São Paulo City. The daily quantitative average of professionals needed for patient care was calculated according to the parameters established by COFEN. The obtained results were compared with the existing number of daily staff members in these units. It was observed that the proportions recommended by COFEN for the nurse category are superior to those used in the hospitals studied, which represents a challenge for Brazilian nursing. Mean care time values were found appropriate and represent important standards for dimensioning the minimum number of professionals in AICU. This study contributed to the validation of the parameters indicated in Resolution 293/04 for nursing staff dimensioning in the AICU.

Habilidades auditivas e medidas da imitância acústica em crianças de 4 a 6 anos de idade

OBJETIVO: avaliar o desempenho em habilidades auditivas e as condições de orelha média de crianças de 4 a 6 anos de idade. MÉTODO: foram aplicados os testes de detecção sonora (audiômetro pediátrico em 20dBNA), a Avaliação Simplificada do Processamento Auditivo (ASPA) e as medidas de imitância acústica (handtymp com tom de 226Hz) em 61 crianças com média de idade de 5,65 anos. Para comparar os resultados das provas de habilidades auditivas e das medidas da imitância acústica foi aplicado o teste exato de Fisher com nível de significância de p< 0,05. RESULTADOS: houve alteração em pelo menos uma das habilidades auditivas investigadas em 24,6% das crianças. Houve alteração timpanométrica em 34,4% das crianças e 64% foram classificadas no critério "falha" para a pesquisa do reflexo acústico ispilateral. As crianças mais jovens apresentaram maior ocorrência de alterações de orelha média, mas não houve diferença estatisticamente significante entre as diferentes idades para as provas realizadas. CONCLUSÃO: as crianças mais jovens apresentaram maior ocorrência de alterações nas provas de habilidades auditivas e nas medidas de imitância acústica. Programas de investigação e acompanhamento das condições de orelha média e das habilidades auditivas em idade pré-escolar e escolar podem eliminar ou minimizar intercorrências que alterariam o desenvolvimento sócio-linguístico.

Sharing decisions in breast cancer care: Development of the Decision Analysis System for Oncology (DAS-O) to identify shared decision making during treatment consultations

Shared Decision Making (SDM) is widely accepted as the preferred method for reaching treatment decisions in the oncology setting including those about clinical trial participation: however, there is some disagreement between researchers over the components of SDM. Specific standardized coding systems are needed to help overcome this difficulty.

Does Mental Illness Affect Consumer Direction of Community-Based Care? Lessons From the Arkansas Cash and Counseling Program

Purpose: Previous research from the Cash and Counseling Demonstration and Evaluation (CCDE) in Arkansas, New Jersey, and Florida suggests that giving consumers control over their personal care greatly increases their satisfaction and improves their outlook on life. Still, some argue that consumerdirected care may not be appropriate for consumers with intellectual disabilities or mental health diagnoses. This study examined how Cash and Counseling— a new option allowing consumers to manage an individualized budget equivalent to what agencies would have spent on their care—changes the way consumers with mental health diagnoses meet their personal care needs and how that affects their wellbeing. Design and Methods: Using the Arkansas CCDE baseline and the 9-month follow-up data for individuals in the treatment and control groups, we compared and contrasted the experience of elderly consumers with and without mental health diagnoses utilizing logit regression. Results: After examining several outcome measures, including satisfaction with care arrangements and the paid caregiver’s reliability and schedule, unmet needs, and satisfaction with the relationship with paid caregivers, this study found evidence that, from the perspective of consumers, the Cash and Counseling program works well for participants with mental health diagnoses. Implications: Considering the growing need for long-term-care services and the limited resources available, a consumer-directed option makes sense, and it can be a valuable alternative for persons with mental health needs.

Transmission dynamics of extended-spectrum β-lactamase-producing Enterobacteriaceae in the tertiary care hospital and the household setting

Studies about transmission rates of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in hospitals and households are scarce.

Point-of-care testing in the cardiovascular operating theatre

Point-of-care testing (POCT) remains under scrutiny by healthcare professionals because of its ill-tried, young history. POCT methods are being developed by a few major equipment companies based on rapid progress in informatics and nanotechnology. Issues as POCT quality control, comparability with standard laboratory procedures, standardisation, traceability and round robin testing are being left to hospitals. As a result, the clinical and operational benefits of POCT were first evident for patients on the operating table. For the management of cardiovascular surgery patients, POCT technology is an indispensable aid. Improvement of the technology has meant that clinical laboratory pathologists now recognise the need for POCT beyond their high-throughput areas.

Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology

Heart failure is a serious condition and equivalent to malignant disease in terms of symptom burden and mortality. At this moment only a comparatively small number of heart failure patients receive specialist palliative care. Heart failure patients may have generic palliative care needs, such as refractory multifaceted symptoms, communication and decision making issues and the requirement for family support. The Advanced Heart Failure Study Group of the Heart Failure Association of the European Society of Cardiology organized a workshop to address the issue of palliative care in heart failure to increase awareness of the need for palliative care. Additional objectives included improving the accessibility and quality of palliative care for heart failure patients and promoting the development of heart failure-orientated palliative care services across Europe. This document represents a synthesis of the presentations and discussion during the workshop and describes recommendations in the area of delivery of quality care to patients and families, education, treatment coordination, research and policy.

Postnatal retention in HIV care: insight from the Swiss HIV Cohort Study over a 15-year observational period.

OBJECTIVES The aim of this study was to quantify loss to follow-up (LTFU) in HIV care after delivery and to identify risk factors for LTFU, and implications for HIV disease progression and subsequent pregnancies. METHODS We used data on pregnancies within the Swiss HIV Cohort Study from 1996 to 2011. A delayed clinical visit was defined as > 180 days and LTFU as no visit for > 365 days after delivery. Logistic regression analysis was used to identify risk factors for LTFU. RESULTS A total of 695 pregnancies in 580 women were included in the study, of which 115 (17%) were subsequent pregnancies. Median maternal age was 32 years (IQR 28-36 years) and 104 (15%) women reported any history of injecting drug use (IDU). Overall, 233 of 695 (34%) women had a delayed visit in the year after delivery and 84 (12%) women were lost to follow-up. Being lost to follow-up was significantly associated with a history of IDU [adjusted odds ratio (aOR) 2.79; 95% confidence interval (CI) 1.32-5.88; P = 0.007] and not achieving an undetectable HIV viral load (VL) at delivery (aOR 2.42; 95% CI 1.21-4.85; P = 0.017) after adjusting for maternal age, ethnicity and being on antiretroviral therapy (ART) at conception. Forty-three of 84 (55%) women returned to care after LTFU. Half of them (20 of 41) with available CD4 had a CD4 count < 350 cells/μL and 15% (six of 41) a CD4 count < 200 cells/μL at their return. CONCLUSIONS A history of IDU and detectable HIV VL at delivery were associated with LTFU. Effective strategies are warranted to retain women in care beyond pregnancy and to avoid CD4 cell count decline. ART continuation should be advised especially if a subsequent pregnancy is planned.

Promoting palliative care in the community: production of the primary palliative care toolkit by the European Association of Palliative Care Taskforce in primary palliative care

BACKGROUND A multidisciplinary European Association of Palliative Care Taskforce was established to scope the extent of and learn what facilitates and hinders the development of palliative care in the community across Europe. AIM To document the barriers and facilitators for palliative care in the community and to produce a resource toolkit that palliative care specialists, primary care health professionals or policymakers, service developers, educationalists and national groups more generally could use to facilitate the development of palliative care in their own country. DESIGN (1) A survey instrument was sent to general practitioners with knowledge of palliative care services in the community in a diverse sample of European countries. We also conducted an international systematic review of tools used to identify people for palliative care in the community. (2) A draft toolkit was then constructed suggesting how individual countries might best address these issues, and an online survey was then set up for general practitioners and specialists to make comments. Iterations of the toolkit were then presented at international palliative care and primary care conferences. RESULTS Being unable to identify appropriate patients for palliative care in the community was a major barrier internationally. The systematic review identified tools that might be used to help address this. Various facilitators such as national strategies were identified. A primary palliative care toolkit has been produced and refined, together with associated guidance. CONCLUSION Many barriers and facilitators were identified. The primary palliative care toolkit can help community-based palliative care services to be established nationally.

Days spent in acute care hospitals at the end of life of cancer patients in four Swiss cantons: a retrospective database study (SAKK 89/09).

Number of days spent in acute hospitals (DAH) at the end of life is regarded as an important care quality indicator for cancer patients. We analysed DAH during 90 days prior to death in patients from four Swiss cantons. Claims data from an insurance provider with about 20% market share and patient record review identified 2086 patients as dying of cancer. We calculated total DAH per patient. Multivariable generalised linear modelling served to evaluate potential explanatory variables. Mean DAH was 26 days. In the multivariable model, using complementary and alternative medicine (DAH = 33.9; +8.8 days compared to non-users) and canton of residence (for patient receiving anti-cancer therapy, Zürich DAH = 22.8 versus Basel DAH = 31.4; for other patients, Valais DAH = 22.7 versus Ticino DAH = 33.7) had the strongest influence. Age at death and days spent in other institutions were additional significant predictors. DAH during the last 90 days of life of cancer patients from four Swiss cantons is high compared to most other countries. Several factors influence DAH. Resulting differences are likely to have financial impact, as DAH is a major cost driver for end-of-life care. Whether they are supply- or demand-driven and whether patients would prefer fewer days in hospital remains to be established.

Attributing inpatient care to diabetes: The case of Medicare for the elderly in Texas, 1995

Specific aims. This study estimated the accuracy of alternative numerator methods for attributing health care utilization and associated costs to diabetes by comparing findings from those methods with findings from a benchmark denominator method. ^ Methods. Using Medicare's 1995 inpatient and enrollment databases for the elderly in Texas, the researcher developed alternative estimates of costs attributable to diabetes. Among alternative numerator methods were selection of all records having diabetes as a principal or secondary diagnosis, and a complex ICD-9-CM sorting routine as previously developed for study of diabetes costs in Texas. Findings from numerator methods were compared with those from a benchmark denominator method based on attributable risk and adapted from a study of national diabetes costs by the American Diabetes Association. This study applied age, gender and ethnicity specific estimates of diabetes prevalence taken from the 1987–94 National Health Interview Surveys to person-months of Medicare Part A, non-HMO enrollment for Texas in 1995. Outcome measures were number of persons identified as having diabetes using alternative definitions of the disease; and number of hospital stays, patient days, and costs using alternative methods for attributing care and costs to diabetes. Cost estimates were based on Medicare payments plus deductibles, co-pays and third party payments. ^ Findings. Numerator methods for attributing costs to diabetes produced findings quite different than those from the benchmark denominator method. When attribution was based on diabetes as principal or secondary diagnosis, the resulting estimates were significantly higher than those obtained from the denominator method. The more complex sorting routine produced estimates near the lower boundary for the confidence interval associated with estimates from the benchmark method. ^ Conclusions. Numerator methods employed by previous researchers poorly estimate the costs of diabetes. While crude mathematical adjustment can be made to the respective numerator approaches, a more useful strategy would be to refine the complex sorting routine to include more hospitalizations. This report recommends approaches to improving methods previously employed in study of diabetes costs. ^

A model of factors determining levels of public support for health care policy in the United States

Public preferences for policy are formed in a little-understood process that is not adequately described by traditional economic theory of choice. In this paper I suggest that U.S. aggregate support for health reform can be modeled as tradeoffs among a small number of behavioral values and the stage of policy development. The theory underlying the model is based on Samuelson, et al.'s (1986) work and Wilke's (1991) elaboration of it as the Greed/Efficiency/Fairness (GEF) hypothesis of motivation in the management of resource dilemmas, and behavioral economics informed by Kahneman and Thaler's prospect theory. ^ The model developed in this paper employs ordered probit econometric techniques applied to data derived from U.S. polls taken from 1990 to mid-2003 that measured support for health reform proposals. Outcome data are four-tiered Likert counts; independent variables are dummies representing the presence or absence of operationalizations of each behavioral variable, along with an integer representing policy process stage. Marginal effects of each independent variable predict how support levels change on triggering that variable. Model estimation results indicate a vanishingly small likelihood that all coefficients are zero and all variables have signs expected from model theory. ^ Three hypotheses were tested: support will drain from health reform policy as it becomes increasingly well-articulated and approaches enactment; reforms appealing to fairness through universal health coverage will enjoy a higher degree of support than those targeted more narrowly; health reforms calling for government operation of the health finance system will achieve lower support than those that do not. Model results support the first and last hypotheses. Contrary to expectations, universal health care proposals did not provide incremental support beyond those targeted to “deserving” populations—children, elderly, working families. In addition, loss of autonomy (e.g. restrictions on choice of care giver) is found to be the “third rail” of health reform with significantly-reduced support. When applied to a hypothetical health reform in which an employer-mandated Medical Savings Account policy is the centerpiece, the model predicts support that may be insufficient to enactment. These results indicate that the method developed in the paper may prove valuable to health policy designers. ^