Technological adoption in health care - The role of payment systems

This paper examines the incentive to adopt a new technology given by some popular reimbursement systems, namely cost reimbursement and DRG reimbursement. Adoption is based on a cost-benefit criterion. We find that retrospective payment systems require a large enough patient benefit to yield adoption, while under DRG, adoption may arise in the absence of patients benefits when the differential reimbursement for the old vs. new technology is large enough. Also, cost reimbursement leads to higher adoption under some conditions on the differential reimbursement levels and patient benefits. In policy terms, cost reimbursement system may be more effective than a DRG payment system. This gives a new dimension to the discussion of prospective vs. retrospective payment systems of the last decades centered on the debate of quality vs. cost containment.

Technological adoption in health care

This paper addresses the impact of payment systems on the rate of technology adoption. We present a model where technological shift is driven by demand uncertainty, increased patients’ benefit, financial variables, and the reimbursement system to providers. Two payment systems are studied: cost reimbursement and (two variants of) DRG. According to the system considered, adoption occurs either when patients’ benefits are large enough or when the differential reimbursement across technologies offsets the cost of adoption. Cost reimbursement leads to higher adoption of the new technology if the rate of reimbursement is high relative to the margin of new vs. old technology reimbursement under DRG. Having larger patient benefits favors more adoption under the cost reimbursement payment system, provided that adoption occurs initially under both payment systems.

Mental health care assessed based on structure, process and outcome : a retrospective cohort study

RESUMO: As doenças mentais são comuns, universais e associadas a uma significativa sobrecarga pessoal, familiar, social e económica. Os Serviços de Saúde Mental devem abordar de forma adequada as necessidades dos pacientes e familiares tanto ao nível clínico como também ao nível social. O presente estudo foi realizado num período de grande transformação nos sistemas de saúde primário e de saúde mental em Portugal, num Departamento de Psiquiatria desenvolvido com base nos princípios da OMS. Os objectivos incluem a caracterização: 1) das Unidades Funcionais do Departamento; 2) dos pacientes internados pela primeira vez no internamento de agudos; 3) da utilização dos serviços nas equipas comunitárias após a alta; e 4) da avaliação de alguns dos indicadores de qualidade do departamento, com recurso ao modelo de Donabedian sobre a articulação entre a Estrutura-Processo-Resultados. Metodologia: Foi escolhido um estudo de coorte retrospectivo. Todos os pacientes internados pela primeira vez entre 2008 e 2010 foram incluídos no estudo. Os seus processos clínicos e a base de dados do hospital onde são registados todos os contactos que estes tiveram com os profissionais de saúde mental foram revistos de forma a obter dados sociodemográficos e clínicos, durante o período do estudo e após a alta. Os instrumentos utilizados foram o WHO-ICMHC (Classificação Internacional de Cuidados de Saúde Mental), para caracterizar o Departamento, o AIESMP (Avaliação Inicial de Enfermagem em Saúde Mental e Psiquiatria) para recolha dos dados sociodemográficos, e o VSSS (Escala de Satisfação com os Serviços de Verona) de forma a avaliar a satisfação dos pacientes em relação aos cuidados recebidos. A análise estatística incluiu a análise descritiva, quantitativa e qualitativa dos dados. Resultados: As Unidades Funcionais do Departamento revelaram níveis elevados de articulação e consistência com as necessidades de cuidados psiquiátricos e reabilitação psicossocial dos pacientes. Os 543 pacientes admitidos pela primeira vez eram maioritariamente (56.9%) mulheres, caucasianas (81.2%), com diagnóstico de perturbações do humor (66.3%), internadas voluntariamente (59.7%), e uma idade média de 45.1 anos. Estas eram significativamente mais velhas, mais frequentemente empregadas, casadas/coabitar e tinham uma prevalência mais elevada de perturbações do humor, comparativamente aos homens. O internamento compulsivo era mais significativo nos homens (54.7%). A taxa de abandono no pós-alta (4.2%) e a taxa de reinternamentos (2.9%) na quinzena após a alta revelaram-se inferiores aos padrões na literatura internacional. De forma global, a satisfação dos pacientes com os cuidados de saúde mental foi positiva. Conclusões: Os cuidados prestados mostraram-se eficazes, adaptados e baseados nas necessidades e problemas específicos dos pacientes. A continuidade e a abrangência de cuidados foram difundidos e mantidos ao longo do processo de cuidados. Este Departamento pode ser considerado um exemplo de como proporcionar tratamento digno e eficiente, e uma referência para futuros serviços de psiquiatria.-------------- ABSTRACT: Mental health disorders are common, universal, and associated with heavy personal, family, social and economic burden. Mental health services should be aimed at adequately addressing patients’ and families’ needs at clinical and social level. The current study was carried out at a time of great transformation in the health and mental health systems in Portugal, in a Psychiatric Department developed taking in consideration the WHO principles. The objectives included characterizing: 1) the Psychiatric Department’s different units; 2) the patients admitted for the first time to the inpatient unit; 3) their use of community mental health services after discharge; and 4) assessing some of the department’s quality indicators, with resource to Donabedian’s Structure-Process-Outcome model. Methodology: A retrospective cohort design was chosen. All the firstly admitted patients in the period between 2008 and 2010 were included in the study. Their clinical records and the hospital’s database which registers all of the contacts the patients had with the mental health professionals during the study period, were reviewed to retrieve sociodemographic and clinical data and information on follow-up. The instruments used were the WHO International Classification of Mental Health Care (ICMHC) to characterize the department, the Initial Nurses’ Assessment in Mental Health and Psychiatry (AIESMP) for patients’ sociodemographic data, and the Verona Service Satisfaction Scale (VSSS) to assess patients’ satisfaction with care received. Statistical analysis included descriptive, quantitative and qualitative analysis of the data. Results: The Department’s Functional units revealed high levels of articulation, and were consistent with patients’ needs for psychiatric care and psychosocial rehabilitation. The 543 patients firstly admitted were mainly (56.9%) female, Caucasian (81.2%), diagnosed with mood disorders (66.3%), voluntarily admitted (59.7%), and with a mean age of 45.1 years. Female patients were significantly older, more frequently employed, married/cohabiting and had a higher prevalence of mood disorders when compared to males. Involuntary admission was more significant in males (54.7%). Dropout rates during follow-up (4.2%) and readmission rates (2.9%) in the fortnight following discharge were lower than standards in international literature. Overall patients’ satisfaction with mental health care was positive. Conclusions: The care delivered was effective, adapted and based on the patients’ specific needs and problems. Continuity and comprehensiveness of care was endorsed and maintained throughout the care process. This department may be considered an example of both humane and effective treatment, and a reference for future psychiatric care.

Catastrophic health care expenditures in Portugal between 2000-2010: Assessing impoverishment, determinants and policy implications

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Economics from the NOVA – School of Business and Economics

Narrative Bifurcation, Cloud Computing Interfaces and Hitchcok

From a narratological perspective, this paper aims to address the theoretical issues concerning the functioning of the so called «narrative bifurcation» in data presentation and information retrieval. Its use in cyberspace calls for a reassessment as a storytelling device. Films have shown its fundamental role for the creation of suspense. Interactive fiction and games have unveiled the possibility of plots with multiple choices, giving continuity to cinema split-screen experiences. Using practical examples, this paper will show how this storytelling tool returns to its primitive form and ends up by conditioning cloud computing interface design.

Narrative Memory in Hyperfiction and Games

The aim of this paper is to address some theoretical issues concerning the narrative practice in cyberspace. From a narratological perspective it intends to clarify the functioning of time and space in storytelling. For that purpose it traces the concept(s) of memory inherited from rhetoric; the use of memory as a narrative device in traditional accounts; the adaptations imposed by hyperfiction. Using practical examples (including two Portuguese case studies - InStory 2006, and Noon 2007) it will show how narrative memory strategies can be helpful in game literacy. The main purpose is to contribute to serious game research and (trans)literary studies.

InStory – The Making of na Interactive Digital Narrative

Em cooperação com Glorianna Davenport do M.I.T. Media Lab

The role of integrated home-based care in patient adherence to antiretroviral therapy

Non-adherence is one of the primary obstacles to successful antiretroviral therapy in HIV+ patients worldwide. In Brazil, the Domiciliary Therapeutic Assistance is a multidisciplinary and integrated home-based assistance program provided for HIV+ patients confined in their homes due to physical deficiency. This study investigated ADT's ability to monitor and promote appropriate adherence to ARV therapy. Fifty-six individuals were recruited from three study groups: Group 1 - patients currently in the ADT program, Group 2 - 21 patients previously treated by the ADT program, and Group 3 - 20 patients who have always been treated using conventional ambulatory care. Using multivariable self-reporting to evaluate adherence, patients in the ADT program had significantly better adherence than patients in ambulatory care (F = 6.66, p = 0.003). This effect was independent of demographic and socioeconomic characteristics as well as medical history. Patients in the ADT program also showed a trend towards greater therapeutic success than ambulatory patients. These results suggest the incorporation of characteristics of ADT in conventional ambulatory care as a strategy to increase adherence to ARV therapy.

Report of a traineeship : audit of antidepressant prescribing in Primary and Mental Care: how to address appropriateness and keep a curb on costs. A tool suitable for all contexts?

RESUMO: Este é o relatório de um estágio realizado na Autoridade de Saúde Local de Bolonha com o objectivo de desenvolver capacidades e competências na área de projectos orientados para a avaliação com base epidemiológica. As prescrições de anti-depressivos aumentaram consideravelmente em todo o mundo durante as últimas décadas. O uso cada vez maior dos agentes mais dispendiosos desempenha um papel na subida do custo dos tratamentos. A Autoridade de Saúde Local de Bolonha implementou um processo de auditoria com o objectivo de melhorar a adequação das prescrições de pacientes externos, centrando-se em dois anti-depressivos de marca ainda protegidos por patente, Escitalopram e Duloxetine. Os Departamentos de Cuidados de Saúde Primários e de Cuidados de Saúde Mental, assim como o Departamento Farmacêutico e a Unidade de Gestão Clínica, estiveram envolvidos na fase de planeamento da auditoria. O grupo da auditoria, maioritariamente composto por médicos de clínica geral e psiquiatras, reuniu e analisou provas da eficácia e segurança dos anti-depressivos. Os dados sobre as prescrições das Unidades de Cuidados de Saúde Primários e dos Centros de Saúde Mental Comunitários da Autoridade de Saúde Local (866.294 habitantes) foram comparados, em particular as taxas de consumo de Escitalopram e Duloxetine. O grupo da auditoria definiu os standards a serem abordados, os indicadores a serem avaliados e as medidas a empreender para atingir os objectivos definidos. As directrizes do NICE sobre a depressão foram escolhidas como referência. O objectivo da auditoria foi definido como evitar o Escitalopram e Duloxetine como medicamentos de primeira escolha num tratamento anti-depressivo. De modo a verificar a eficácia das medidas empreendidas foi seleccionado um indicador, consistindo numa redução de 25% das prescrições de ambos os anti-depressivos na prática clínica de pacientes externos e numa redução de 20% da variabilidade nas Unidades de Cuidados de Saúde Primários. O relatório retrospectivo pré-auditoria (Janeiro a Abril de 2012) revelou que os tratamentos com anti-depressivos para pacientes externos eram prescritos pelos médicos de clínica geral em mais de90% dos casos. As medidas da auditoria foram implementadas entre Novembro de 2012 e Maio de 2013. Algumas medidas relevantes foram integradas com a revisão da auditoria, tais como reuniões educacionais de pequena escala com os médicos de clínica geral e psiquiatras, visitas de apoio do assessor de prescrições da Autoridade de Saúde Local aos médicos de clínica geral e Centros de Saúde Mental Comunitários, panfletos para profissionais com informação retirada das directrizes clínicas do NICE, implementação de um serviço de consulta na Web para médicos de clínica geral sobre provas relativas a anti-depressivos. O relatório de feedback é aguardado em Novembro de 2013 depois de se verificar nos standards atingidos a eficácia das medidas implementadas. Foi realizada uma análise SWOT para comprovar as forças e fraquezas, as oportunidades e ameaças do processo. Como identificação de fraquezas poderá ser útil identificar estratégias relevantes para melhoria interna, para que o conhecimento das ameaças possa amortizar factores que possam ter impactos adversos que fujam ao controlo do Departamento de Saúde Mental. Uma melhor compreensão das forças e das oportunidades facilita a consecução dos objectivos estabelecidos no projecto. O primeiro, mas não o último, resultado deste processo consistiu numa maior integração entre os Cuidados de Saúde Primários e de Saúde Mental, permitindo assim que a Autoridade de Saúde Local coloque as alterações em prática.------------ABSTRACT: This is the report of a traineeship held in the Local Health Authority of Bologna with the aim to develop skills and competencies in the field of epidemiogically based evaluation oriented projects. Antidepressants prescriptions have considerably increased all over the world in the last decades. The increasing use of the most expensive agents plays a part in the rising cost of treatments. The Local Health Authority of Bologna has implemented an audit process aimed at improving the appropriateness of outpatient prescriptions focusing on the two branded antidepressants still protected by patent, Escitalopram and Duloxetine. The Primary Care and the Mental Health Care Departments, as well as the Pharmaceutical Department and the Clinical Governance Unit, were involved in the planning phase of the audit. The audit group, mainly composed of general practitioners and psychiatrists, collected and analyzed scientific evidence on effectiveness and safety of antidepressants. Data on prescriptions of Primary Care Units and Community Mental Health Centers of the Local Health Authority (866.294 inhabitants) were compared, in particular consumption rates of Escitalopram and Duloxetine. The audit group defined the standards to be addressed, the indicators to be evaluated and the actions aimed at reaching the defined goals. NICE guidelines on depression were chosen as reference. The aim of the audit was settled as avoiding Escitalopram and Duloxetine as first choice drugs starting an AD treatment. In order to check the efficacy of the actions undertaken an indicator was selected, consisting in a reduction of 25% of prescriptions of both ADs in outpatient practice and in a 20% reduction of To develop skills and competencies across Primary Care Units. The pre-audit retrospective report (January-April 2012) showed that outpatient antidepressant treatments were prescribed by GPs in over 90% of cases. Audit actions were implemented between November 2012 and May 2013. Some relevant actions have been integrated with the audit review, such as small-scale educational meetings with GPs and psychiatrists, outreach visits of the LHA prescribing adviser to GPs and CMHCs,leaflets for professionals with information extracted from NICE clinical guidelines, implementation of a web consultation service for GPs about evidence on antidepressants. The feedback report is expected in November 2013 after checking through the standards attained the effectiveness of actions implemented. A SWOT Analysis was carried out to evidence the strengths and weaknesses, opportunities and threats of the process. As identification of weaknesses may be useful to identify relevant strategies for internal improvement, so the knowledge of threats can amortize factors that may have adverse impacts beyond the control of the Mental Health Department. Better understanding of the strengths and the opportunities facilitates the achievement of the goals set in the project. The first and not least upshot of this process has consisted in further integration between Primary and Mental Health Care, thus enabling the LHA to put the change into practice.

An assessment of the integration of the mental health component into the care of women affected by intimate partner violence in Peru

RESUMO: A violência contra as mulheres (VCM) é um problema de saúde pública e uma violação dos direitos humanos. Ele tem uma alta prevalência na América Latina e no Caribe; o Estudo da Violência Contra as Mulheres da Organização Mundial de Saúde (OMS) identificou que as mulheres peruanas sofrem o maior índice de violência. O Perú é signatário da CEDAW e da Convenção de Belém do Pará, com recomendações para resolver este tipo de discriminação e descrever o papel do setor da saúde. A lei peruana define a violência como um problema de saúde mental. Objectivos: As três orientações clínicas do Ministério da Saúde para avaliar a integração da componente de saúde mental no cuidado de mulheres afetadas pela VCM foram revistas. Método: A proteção da saúde mental foi avaliada nas orientações acima mencionadas. A lei peruana relevante para perceber o reconhecimento das consequências de VCM na saúde mental e os cuidados prestados neste contexto foram revistos. Usando esses padrões nacionais e internacionais, foi realizada uma análise de conteúdo dos guias peruanos para a atenção da violência para ver como eles se integram a saúde mental. Resultados: Estas orientações são muito extensas e não definem claramente a responsabilidade dos profissionais de saúde. Não incluem um exame de saúde mental na avaliação da vítima e são vagas na descrição das atividades a serem realizadas pelo prestador dos cuidados de saúde. As orientações recomendam uma triagem universal usando um instrumento com formato antiquado e pesado. Em contrapartida, as orientações da OMS não recomendam qualquer triagem. Conclusão: As várias orientações analisadas não fornecem a informação necessária para o profissional de saúde avaliar o envolvimento da saúde mental e, desnecessariamente, tratam as mulheres sobreviventes de VCM como doentes mentais. Recomenda-se que as orientações recentes da OMS (Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines, 2013) para os cuidados de VCM sejam usadas como um modelo para o desenvolvimento de um único dispositivo técnico que incorpora directrizes com base científica. legislação com base no género, saúde, guias, prevenção e mujeres 6 RESUMO (PORTUGUESE) A violência contra as mulheres (VCM) é um problema de saúde pública e uma violação dos direitos humanos. Ele tem uma alta prevalência na América Latina e no Caribe; o Estudo da Violência Contra as Mulheres da Organização Mundial de Saúde (OMS) identificou que as mulheres peruanas sofrem o maior índice de violência. O Perú é signatário da CEDAW e da Convenção de Belém do Pará, com recomendações para resolver este tipo de discriminação e descrever o papel do setor da saúde. A lei peruana define a violência como um problema de saúde mental. Objectivos: As três orientações clínicas do Ministério da Saúde para avaliar a integração da componente de saúde mental no cuidado de mulheres afetadas pela VCM foram revistas. Método: A proteção da saúde mental foi avaliada nas orientações acima mencionadas. A lei peruana relevante para perceber o reconhecimento das consequências de VCM na saúde mental e os cuidados prestados neste contexto foram revistos. Usando esses padrões nacionais e internacionais, foi realizada uma análise de conteúdo dos guias peruanos para a atenção da violência para ver como eles se integram a saúde mental. Resultados: Estas orientações são muito extensas e não definem claramente a responsabilidade dos profissionais de saúde. Não incluem um exame de saúde mental na avaliação da vítima e são vagas na descrição das atividades a serem realizadas pelo prestador dos cuidados de saúde. As orientações recomendam uma triagem universal usando um instrumento com formato antiquado e pesado. Em contrapartida, as orientações da OMS não recomendam qualquer triagem. Conclusão: As várias orientações analisadas não fornecem a informação necessária para o profissional de saúde avaliar o envolvimento da saúde mental e, desnecessariamente, tratam as mulheres sobreviventes de VCM como doentes mentais. Recomenda-se que as orientações recentes da OMS (Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines, 2013) para os cuidados de VCM sejam usadas como um modelo para o desenvolvimento de um único dispositivo técnico que incorpora directrizes com base científica.-----------------ABSTRACT: Violence against women (VAW) is a public health problem and a human rights violation. It is highly prevalent in Latin America and the Caribbean; the Multi-country Study on Violence against Women by the World Health Organization identified rural Peruvian women as suffering the highest rates of VAW. The country is party to CEDAW and Belen Do Para Conventions, which set forth recommendations to overcome this form of discrimination and describe the role of the health sector. Peruvian law defines violence as a mental health issue. Objective: The Ministry of Health’s three technical guidelines were reviewed to assess the integration of mental health into the care of women affected by violence Method: The protection of the woman’s mental health was ascertained in the conventions mentioned above. The recognition of the mental health consequences of VAW and the inclusion of its evaluation and care were assessed in pertinent Peruvian legislation. Using these international and national parameters, the three guidelines for the attention of violence were subject to content analysis to see whether they conform to the conventions and integrate mental health care. Outcome: These guidelines are too extensive and do not clearly define the responsibility of health workers. They do not include a mental health exam in the evaluation of the victim and are vague in the description of the actions to be carried out by the health care provider. Guidelines prescribe universal screening using an outdated instrument and moreover, WHO Guidelines do not recommend screening. Conclusion: These multiple guidelines do not provide useful guidance for health care providers, particularly for the assessment of mental health sequelae, and unnecessarily stigmatize survivors of violence as mentally ill. It is recommended that the World Health Organization’s document Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines (2013) be used as a blueprint for only one technical instrument that incorporates evidence -based national policy and guidelines.

Contributo para a validação da versão portuguesa do instrumento de avaliação VOICE (service users perceptions of impatient care, Views on Inpatient Care)

RESUMO: Nos últimos anos assistiu-se a um reposicionamento das pessoas portadoras de doença mental na sociedade, no sentido de viverem em pleno os seus direitos, sem restrições. Esta tendência acompanhou as transformações que se têm vivido na forma como os utentes dos serviços de saúde interagem com os mesmos e com os profissionais de saúde, de forma a permitir uma maior autonomização e responsabilização no que concerne ao tratamento da sua doença, a relação que estabelecem com o seu médico, e a participação na avaliação e monitorização da qualidade dos serviços. Mais recentemente, também no mundo científico, esta afirmação se fez sentir, com o surgimento de investigação liderada por utentes, no sentido de estudar de forma adequada questões que partem do seu ponto de vista, e que possibilitem a produção de conhecimento significativa no contexto das suas experiências. Com o presente trabalho pretende-se contribuir para a validação da versão portuguesa do VOICE (Service Users’ Perceptions of Inpatient Care, Views on Inpatient Care) (Evans et al., 2012), instrumento para a avaliação dos serviços de internamento de agudos em psiquiatria, construído a partir de um investigação liderado por utentes e partindo das suas perspectiva. O VOICE é constituído por 19 questões, agrupadas em sete domínios: admissão; cuidados e tratamento; medicação; equipa de técnicos do internamento; terapia e atividades; ambiente e diferenças. O presente estudo envolveu uma amostra de 85 utentes de um serviço de internamento de agudos de uma instituição psiquiátrica do Norte de Portugal. A versão portuguesa do VOICE apresentou boa aceitação por parte dos utentes e boas características psicométricas - a consistência interna foi alta (α = 0,87) e todos, exceto um item (item 6), apresentam elevadas correlações item-total (variando de 0,18 - item 6 a 0,71 - item 11; M = 0,54, DP = 0,15), sugerindo ser um instrumento útil na avaliação dos serviços de internamento de agudos. No futuro torna-se necessário alargar o estudo a outros contextos de internamento e envolvendo amostras mais alargadas.-------------- ABSTRACT: In recent years there has been a gradual process to help people with the experience of mental illness regaining their full rights. Following the advances in the understanding of mental health problems, and the use of medication to help patients overcome symptoms, service-users have become more autonomous and responsible in the way they deal with health professionals, and are now called to participate in assessing and monitoring mental health services and policies. In the context of these transformations we have assisted to the emergence of research led by service-users (in this case of psychiatric and mental health services) in order to emphasize their point of view, and to enable the production of significant knowledge resulting from their experiences, and perceptions. The present study aims to contribute to the dissemination of service-user led research, based on the adaptation and validation of the Portuguese version of the VOICE - Service Users' Perceptions Questionnaire, Views on Inpatient Care. (Evans et al., 2012). The VOICE is composed of 19 questions, grouped in seven domains: admissions, care and treatment, medication, team of technicians during hospitalization, therapy and activities, environment and diversity. The present study involved a sample of 85 inpatient of a psychiatric institution in Northern Portugal. The Portuguese version of the VOICE showed good psychometric properties and was well accepted by patients [high internal consistency (α = 0,87); and high correlation of each item, except item 6, with the total score (ranging from 0.18 on item 6 to 0.71 on item 11; average=0,54; SD=0,15), suggesting it to be a useful tool for assessing inpatient services. In the future there is a need to extend the study to other contexts and include larger samples.

Integrated care approaches and skills mix policies in Europe

ABSTRACT - Background: Integration of health care services is emerging as a central challenge of health care delivery, particularly for patients with elderly and complex chronic conditions. In 2003, the World Health Organization (WHO) already began to identify it as one of the key pathways to improve primary care. In 2005, the European Commission declared integrated care as vital for the sustainability of social protection systems in Europe. Nowadays, it is recognized as a core component of health and social care reforms across European countries. Implementing integrated care requires coordination between settings, organizations, providers and professionals. In order to address the challenge of integration in such complex scenario, an effective workforce is required capable of working across interdependent settings. The World Health Report 2006 noted that governments should prepare their workforce and explore what tasks the different levels of health workers are trained to do and are capable of performing (skills mix). Comparatively to other European countries, Portugal is at an early stage in what integrated care is concerned facing a growing elderly population and the subsequent increase in the pressure on institutions and professionals to provide social and medical care in the most cost-effective way. In 2006 the Portuguese government created the Portuguese Network for Integrated Care Development (PNICD) to solve the existing long-term gap in social support and healthcare. On what concerns health workforce, the Portuguese government already recognized the importance of redefine careers keeping professional motivation and satisfaction. Aim of the study: This study aims to contribute new evidence to the debate surrounding integrated care and skills mix policies in Europe. It also seeks to provide the first evidence that incorporates both the current dynamics of implementing integrated care in Portugal and the developments of international literature. The first ambition of our study is to contribute to the growing interest in integrated care and to the ongoing research in this area by identifying its different approaches and retrieve a number of experiences in some European countries. Our second goal of this research is to produce an update on the knowledge developed on skills mix to the international healthcare management community and to policy makers involved in reforming healthcare systems and organizations. To better inform Portuguese health policies makers in a third stage we explore the current dynamics of implementing integrated care in Portugal and contextualize them with the developments reported in the international literature. Methodology: This is essentially an exploratory and descriptive study using qualitative methodology. In order to identify integrated care approaches in Europe, a systematic literature review was undertaken which resulted in a paper published in the Journal of Management and Marketing in Health care titled: Approaches to developing integrated care in Europe: a systematic literature review. This article was recommended and included into a list of references identified by The King's Fund Library. A second systematic literature review was undertaken which resulted in a paper published in the International Journal of Healthcare Management titled: Skills mix in healthcare: An international update for the management debate. Semi-structured interviews were performed on experts representing the regional coordination teams of the Portuguese Network for Integrated Care Development. In a last stage a questionnaire survey was developed based on the findings of both systematic literature reviews and semi-structured interviews. Conclusions: Even though integrated care is a worldwide trend in health care reforms, there is no unique definition. Definitions can be grouped according to their sectorial focus: community-based care, combined health and social care, combined acute and primary care, the integration of providers, and in a more comprehensive approach the whole health system. Indeed, models that seek to apply the principles of integrated care have a similar background and are continually evolving and depend on the different initiatives taken at national level. . Despite the fact that we cannot argue that there is one single set typology of models for integrated care, it is possible to identify and categorize some of the basic approaches that have been taken in attempts to implement integrated care according to: changes in organizational structure, workforce reconfiguring, and changes in the financing system. The systematic literature review on skills mix showed that despite the widely acknowledged interest on skills mix initiatives there is a lack of evidence on skills mix implications, constraints, outcomes, and quality impact that would allow policy makers to take sustained and evidence-based decisions. Within the Portuguese health system, the integrated care approach is rather organizational and financial, whereas little attention is given to workforce integration. On what concerns workforce planning Portugal it is still in the stage of analyzing the acceptability of health workforce skills mix. In line with the international approaches, integration of health and social services and bridging primary and acute care are the main goals of the national government strategy. The findings from our interviews clarify perceptions which show no discrepancy with the related literature but are rather scarce comparing to international experience. Informants hold a realistic but narrow view of integrated care related issues. They seem to be limited to the regional context, requiring a more comprehensive perspective. The questionnaire developed in this thesis is an instrument which, when applied, will allow policy makers to understand the basic set of concepts and managerial motivations behind national and regional integrated care programs. The instrument developed can foster evidence on the three essential components of integrated care policies: organizational, financial, and human resources development, and can give additional input on the context in which integrated care is being developed, the type of providers and organizations involved, barriers and constraints, and the workforce skills mix planning related strategies. The thesis was successful in recognizing differences between countries and interventions and the instrument developed will allow a better comprehension of the international options available and how to address the vital components of integrated care programs.

Nosocomial infections in a Brazilian neonatal intensive care unit: a 4-year surveillance study

INTRODUCTION: Report the incidence of nosocomial infections, causative microorganisms, risk factors associated with and antimicrobial susceptibility pattern in the NICU of the Uberlândia University Hospital. METHODS: Data were collected through the National Healthcare Safety Network surveillance from January 2006 to December 2009. The patients were followed five times/week from their birth to their discharge or death. RESULTS: The study included 1,443 patients, 209 of these developed NIs, totaling 293 NI episodes, principally bloodstream infections (203; 69.3%) and conjunctivitis (52; 17.7%). Device-associated infection rates were as follows: 17.3 primary bloodstream infections per 1,000 central line-days and 3.2 pneumonias per 1000 ventilator-days. The mortality rate in neonates with NI was 11.9%. Mechanical ventilation, total parenteral nutrition, orogastric tube, previous antibiotic therapy, use of CVC and birth weight of 751-1,000g appeared to be associated with a significantly higher risk of NI (p < 0.05). In multiple logistic regression analysis for NI, mechanical ventilation and the use of CVC were independent risk factors (p < 0.05). Coagulase- negative Staphylococcus (CoNS) (36.5%) and Staphylococcus aureus (23.6%) were the most common etiologic agents isolated from cultures. The incidences of oxacillin-resistant CoNS and S. aureus were 81.8% and 25.3%, respectively. CONCLUSIONS: Frequent surveillance was very important to evaluate the association of these well-known risk factors with NIs and causative organisms, assisting in drawing the attention of health care professionals to this potent cause of morbidity.

Métodos de avaliação do impacto económico dos eventos adversos em meio hospitalar

RESUMO - O sistema de saúde é constantemente sujeito a pressões sendo as mais relevantes a pressão para o aumento da qualidade e a necessidade de contenção de custos. Os Eventos Adversos (EAs) ocorridos em meio hospitalar constituem um sério problema de qualidade na prestação de cuidados de saúde, com consequências clinicas, sociais, económicas e de imagem, que afectam pacientes, profissionais, organizações e o próprio sistema de saúde. Os custos associados à ocorrência de EAs em meio hospitalar, incrementam significativamente os custos hospitalares, representando cerca de um em cada sete dólares gastos no atendimento dos doentes. Só na última década surgiram estudos com o objectivo principal de avaliar esse impacto em meio hospitalar, subsistindo ainda uma grande indefinição quanto às variáveis e métodos a utilizar. O objectivo principal deste trabalho de projecto foi conhecer e caracterizar as diferentes metodologias utilizadas para avaliação dos custos económicos, nomeadamente dos custos directos, relacionados com a ocorrência de eventos adversos em meio hospitalar. Tendo em atenção as dificuldades referidas, utilizou-se como metodologia a revisão narrativa da literatura, complementada com a realização de uma técnica de grupo nominal. Os resultados obtidos foram os seguintes: i) a metodologia utilizada na maioria dos estudos para determinar a frequência, natureza e consequências dos EAs ocorridos em meio hospitalar, utiliza matrizes de base observacional, analítica, com base em estudos de coorte retrospectivo recorrendo aos critérios definidos pelo Harvard Medical Practice Study; ii) a generalidade dos estudos realizados avaliam os custos directos dos EAs em meio hospitalar, iii) verificou-se a existência de uma grande diversidade de métodos para a determinação dos custos associados aos EAs. A generalidade dos estudos determina esse valor com base na contabilização do número de dias adicionais de internamento, resultantes do EA, valorizados com base em custos médios; iv) o grupo de peritos, propôs como metodologia para a determinação do custo associado a cada EA, a utilização de sistemas de custeio por doente; v) propõe-se o desenvolvimento de uma plataforma informática, que permita o cruzamento da informação disponível no registo clinico electrónico do doente com um sistema automático de identificação de EAs, a desenvolver, e com sistemas de custeio por doente, de modo a valorizar os custos por doente e por tipo de EA. A avaliação dos custos directos associados à ocorrência de EAs em contexto hospitalar, pelo impacto económico e social que tem nos doentes e organizações, será seguramente uma das áreas de estudo e investigação futuras, no sentido de melhorar a eficiência do sistema de saúde e a qualidade e segurança dos cuidados prestados aos doentes.