Diagnóstico e análise da rede social: o caso da prestação de cuidados continuados a crianças com diabetes

Mestrado em Intervenção Sócio-Organizacional na Saúde - Ramo de especialização: Qualidade e Tecnologias da Saúde

An integrated recycling approach for GFRP pultrusion wastes: recycling and reuse assessment into new composite materials using Fuzzy Boolean Nets

In this study, efforts were made in order to put forward an integrated recycling approach for the thermoset based glass fibre reinforced polymer (GPRP) rejects derived from the pultrusion manufacturing industry. Both the recycling process and the development of a new cost-effective end-use application for the recyclates were considered. For this purpose, i) among the several available recycling techniques for thermoset based composite materials, the most suitable one for the envisaged application was selected (mechanical recycling); and ii) an experimental work was carried out in order to assess the added-value of the obtained recyclates as aggregates and reinforcement replacements into concrete-polymer composite materials. Potential recycling solution was assessed by mechanical behaviour of resultant GFRP waste modified concrete-polymer composites with regard to unmodified materials. In the mix design process of the new GFRP waste based composite material, the recyclate content and size grade, and the effect of the incorporation of an adhesion promoter were considered as material factors and systematically tested between reasonable ranges. The optimization process of the modified formulations was supported by the Fuzzy Boolean Nets methodology, which allowed finding the best balance between material parameters that maximizes both flexural and compressive strengths of final composite. Comparing to related end-use applications of GFRP wastes in cementitious based concrete materials, the proposed solution overcome some of the problems found, namely the possible incompatibilities arisen from alkalis-silica reaction and the decrease in the mechanical properties due to high water-cement ratio required to achieve the desirable workability. Obtained results were very promising towards a global cost-effective waste management solution for GFRP industrial wastes and end-of-life products that will lead to a more sustainable composite materials industry.

A checklist for patient safety rounds at the care pathway level

Objective - To define a checklist that can be used to assess the performance of a department and evaluate the implementation of quality management (QM) activities across departments or pathways in acute care hospitals. Design - We developed and tested a checklist for the assessment of QM activities at department level in a cross-sectional study using on-site visits by trained external auditors. Setting and Participants - A sample of 292 hospital departments of 74 acute care hospitals across seven European countries. In every hospital, four departments for the conditions: acute myocardial infarction (AMI), stroke, hip fracture and deliveries participated. Main outcome measures - Four measures of QM activities were evaluated at care pathway level focusing on specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies and clinical review (CR). Results - Participating departments attained mean values on the various scales between 1.2 and 3.7. The theoretical range was 0-4. Three of the four QM measures are identical for the four conditions, whereas one scale (EBOP) has condition-specific items. Correlations showed that every factor was related, but also distinct, and added to the overall picture of QM at pathway level. Conclusion - The newly developed checklist can be used across various types of departments and pathways in acute care hospitals like AMI, deliveries, stroke and hip fracture. The anticipated users of the checklist are internal (e.g. peers within the hospital and hospital executive board) and external auditors (e.g. healthcare inspectorate, professional or patient organizations).

Towards a Unified Theory of Health-Disease: I. Health as a complex model-object

Theory building is one of the most crucial challenges faced by basic, clinical and population research, which form the scientific foundations of health practices in contemporary societies. The objective of the study is to propose a Unified Theory of Health-Disease as a conceptual tool for modeling health-disease-care in the light of complexity approaches. With this aim, the epistemological basis of theoretical work in the health field and concepts related to complexity theory as concerned to health problems are discussed. Secondly, the concepts of model-object, multi-planes of occurrence, modes of health and disease-illness-sickness complex are introduced and integrated into a unified theoretical framework. Finally, in the light of recent epistemological developments, the concept of Health-Disease-Care Integrals is updated as a complex reference object fit for modeling health-related processes and phenomena.

Renewable energy in Islands: an integrated proposal for electricity generation and transports

The purpose of this article is to analyse and evaluate the economical, energetic and environmental impacts of the increasing penetration of renewable energies and electrical vehicles in isolated systems, such as Terceira Island in Azores and Madeira Island. Given the fact that the islands are extremely dependent on the importation of fossil fuels - not only for the production of energy, but also for the transportation’s sector – it’s intended to analyse how it is possible to reduce that dependency and determine the resultant reduction of pollutant gas emissions. Different settings have been analysed - with and without the penetration of EVs. The Terceira Island is an interesting case study, where EVs charging during off-peak hours could allow an increase in geothermal power, limited by the valley of power demand. The percentage of renewable energy in the electric power mix could reach the 74% in 2030 while at the same time, it is possible to reduce the emissions of pollutant gases in 45% and the purchase of fossil fuels in 44%. In Madeira, apart from wind, solar and small hydro power, there are not so many endogenous resources and the Island’s emission factor cannot be so reduced as in Terceira. Although, it is possible to reduce fossil fuels imports and emissions in 1.8% in 2030 when compared with a BAU scenario with a 14% of the LD fleet composed by EVs.

Renewable energy in Islands: an integrated proposal for electricity generation and transports

The purpose of this article is to analyse and evaluate the economical, energetic and environmental impacts of the increasing penetration of renewable energies and electrical vehicles in isolated systems, such as Terceira Island in Azores and Madeira Island. Given the fact that the islands are extremely dependent on the importation of fossil fuels - not only for the production of energy, but also for the transportation’s sector – it’s intended to analyse how it is possible to reduce that dependency and determine the resultant reduction of pollutant gas emissions. Different settings have been analysed - with and without the penetration of EVs. The Terceira Island is an interesting case study, where EVs charging during off-peak hours could allow an increase in geothermal power, limited by the valley of power demand. The percentage of renewable energy in the electric power mix could reach the 74% in 2030 while at the same time, it is possible to reduce the emissions of pollutant gases in 45% and the purchase of fossil fuels in 44%. In Madeira, apart from wind, solar and small hydro power, there are not so many endogenous resources and the Island’s emission factor cannot be so reduced as in Terceira. Although, it is possible to reduce fossil fuels imports and emissions in 1.8% in 2030 when compared with a BAU scenario with a 14% of the LD fleet composed by EVs.

An integrated approach for TQM implementation in SMEs

This paper tackles the broad issue of TQM implementation in SMEs. It includes a review of two models aimed at improving organisational performance, the EFQM Excellence Model and the Balanced Scorecard, which have been widely used in large organisations. Both models are examined as to their suitability and applicability to small and medium sized enterprises. The findings indicate that SMEs can benefit from the adoption of an integrated approach that combines both models if some critical factors are considered in the implementation process. A theoretical framework is proposed, which considers such integration and leads to a gradual implementation of TQM principles and methods in SMEs.

Integrated analysis of climate, soil, topography and vegetative growth in Iberian viticultural regions

The Iberian viticultural regions are convened according to the Denomination of Origin (DO) and present different climates, soils, topography and management practices. All these elements influence the vegetative growth of different varieties throughout the peninsula, and are tied to grape quality and wine type. In the current study, an integrated analysis of climate, soil, topography and vegetative growth was performed for the Iberian DO regions, using state-of-the-art datasets. For climatic assessment, a categorized index, accounting for phenological/thermal development, water availability and grape ripening conditions was computed. Soil textural classes were established to distinguish soil types. Elevation and aspect (orientation) were also taken into account, as the leading topographic elements. A spectral vegetation index was used to assess grapevine vegetative growth and an integrated analysis of all variables was performed. The results showed that the integrated climate-soil-topography influence on vine performance is evident. Most Iberian vineyards are grown in temperate dry climates with loamy soils, presenting low vegetative growth. Vineyards in temperate humid conditions tend to show higher vegetative growth. Conversely, in cooler/warmer climates, lower vigour vineyards prevail and other factors, such as soil type and precipitation acquire more important roles in driving vigour. Vines in prevailing loamy soils are grown over a wide climatic diversity, suggesting that precipitation is the primary factor influencing vigour. The present assessment of terroir characteristics allows direct comparison among wine regions and may have great value to viticulturists, particularly under a changing climate.

Deported Mexican migrants: health status and access to care

OBJECTIVE To describe the health status and access to care of forced-return Mexican migrants deported through the Mexico-United States border and to compare it with the situation of voluntary-return migrants. METHODS Secondary data analysis from the Survey on Migration in Mexico’s Northern Border from 2012. This is a continuous survey, designed to describe migration flows between Mexico and the United States, with a mobile-population sampling design. We analyzed indicators of health and access to care among deported migrants, and compare them with voluntary-return migrants. Our analysis sample included 2,680 voluntary-return migrants, and 6,862 deportees. We employ an ordinal multiple logistic regression model, to compare the adjusted odds of having worst self-reported health between the studied groups. RESULTS As compared to voluntary-return migrants, deportees were less likely to have medical insurance in the United States (OR = 0.05; 95%CI 0.04;0.06). In the regression model a poorer self-perceived health was found to be associated with having been deported (OR = 1.71, 95%CI 1.52;1.92), as well as age (OR = 1.03, 95%CI 1.02;1.03) and years of education (OR = 0.94 95%CI 0.93;0.95). CONCLUSIONS According to our results, deportees had less access to care while in the United States, as compared with voluntary-return migrants. Our results also showed an independent and statistically significant association between deportation and having poorer self-perceived health. To promote the health and access to care of deported Mexican migrants coming back from the United States, new health and social policies are required.

Exact admission-control for integrated aperiodic and periodic tasks

Admission controllers are used to prevent overload in systems with dynamically arriving tasks. Typically, these admission controllers are based on suÆcient (but not necessary) capacity bounds in order to maintain a low computational complexity. In this paper we present how exact admission-control for aperiodic tasks can be eÆciently obtained. Our rst result is an admission controller for purely aperiodic task sets where the test has the same runtime complexity as utilization-based tests. Our second result is an extension of the previous controller for a baseload of periodic tasks. The runtime complexity of this test is lower than for any known exact admission-controller. In addition to presenting our main algorithm and evaluating its performance, we also discuss some general issues concerning admission controllers and their implementation.

Phytotherapy in primary health care

OBJECTIVE To characterize the integration of phytotherapy in primary health care in Brazil. METHODS Journal articles and theses and dissertations were searched for in the following databases: SciELO, Lilacs, PubMed, Scopus, Web of Science and Theses Portal Capes, between January 1988 and March 2013. We analyzed 53 original studies on actions, programs, acceptance and use of phytotherapy and medicinal plants in the Brazilian Unified Health System. Bibliometric data, characteristics of the actions/programs, places and subjects involved and type and focus of the selected studies were analyzed. RESULTS Between 2003 and 2013, there was an increase in publications in different areas of knowledge, compared with the 1990-2002 period. The objectives and actions of programs involving the integration of phytotherapy into primary health care varied: including other treatment options, reduce costs, reviving traditional knowledge, preserving biodiversity, promoting social development and stimulating inter-sectorial actions. CONCLUSIONS Over the past 25 years, there was a small increase in scientific production on actions/programs developed in primary care. Including phytotherapy in primary care services encourages interaction between health care users and professionals. It also contributes to the socialization of scientific research and the development of a critical vision about the use of phytotherapy and plant medicine, not only on the part of professionals but also of the population.

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.

Regional governance: strategies and disputes in health region management

OBJECTIVE To analyze the regional governance of the health systemin relation to management strategies and disputes.METHODOLOGICAL PROCEDURES A qualitative study with health managers from 19 municipalities in the health region of Bahia, Northeastern Brazil. Data were drawn from 17 semi-structured interviews of state, regional, and municipal health policymakers and managers; a focus group; observations of the regional interagency committee; and documents in 2012. The political-institutional and the organizational components were analyzed in the light of dialectical hermeneutics.RESULTS The regional interagency committee is the chief regional governance strategy/component and functions as a strategic tool for strengthening governance. It brings together a diversity of members responsible for decision making in the healthcare territories, who need to negotiate the allocation of funding and the distribution of facilities for common use in the region. The high turnover of health secretaries, their lack of autonomy from the local executive decisions, inadequate technical training to exercise their function, and the influence of party politics on decision making stand as obstacles to the regional interagency committee’s permeability to social demands. Funding is insufficient to enable the fulfillment of the officially integrated agreed-upon program or to boost public supply by the system, requiring that public managers procure services from the private market at values higher than the national health service price schedule (Brazilian Unified Health System Table). The study determined that “facilitators” under contract to health departments accelerated access to specialized (diagnostic, therapeutic and/or surgical) services in other municipalities by direct payment to physicians for procedure costs already covered by the Brazilian Unified Health System.CONCLUSIONS The characteristics identified a regionalized system with a conflictive pattern of governance and intermediate institutionalism. The regional interagency committee’s managerial routine needs to incorporate more democratic devices for connecting with educational institutions, devices that are more permeable to social demands relating to regional policy making.

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.

Hospitalization of older adults due to ambulatory care sensitive conditions

OBJECTIVE To analyze the temporal evolution of the hospitalization of older adults due to ambulatory care sensitive conditions according to their structure, magnitude and causes. METHODS Cross-sectional study based on data from the Hospital Information System of the Brazilian Unified Health System and from the Primary Care Information System, referring to people aged 60 to 74 years living in the state of Rio de Janeiro, Souhteastern Brazil. The proportion and rate of hospitalizations due to ambulatory care sensitive conditions were calculated, both the global rate and, according to diagnoses, the most prevalent ones. The coverage of the Family Health Strategy and the number of medical consultations attended by older adults in primary care were estimated. To analyze the indicators’ impact on hospitalizations, a linear correlation test was used. RESULTS We found an intense reduction in hospitalizations due to ambulatory care sensitive conditions for all causes and age groups. Heart failure, cerebrovascular diseases and chronic obstructive pulmonary diseases concentrated 50.0% of the hospitalizations. Adults older than 69 years had a higher risk of hospitalization due to one of these causes. We observed a higher risk of hospitalization among men. A negative correlation was found between the hospitalizations and the indicators of access to primary care. CONCLUSIONS Primary healthcare in the state of Rio de Janeiro has been significantly impacting the hospital morbidity of the older population. Studies of hospitalizations due to ambulatory care sensitive conditions can aid the identification of the main causes that are sensitive to the intervention of the health services, in order to indicate which actions are more effective to reduce hospitalizations and to increase the population’s quality of life.