The impact of the economic crisis on the quality of health services

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

An internal analysis of Amorim Turismo’s operations regarding food and beverage with a focus on operational efficiency and quality of service

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

Quality of process modeling using BPMN: a model-driven approach

Dissertação para obtenção do Grau de Doutor em Engenharia Informática

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.

Groundwater quality, vulnerability and potential assessment in Kobo Valley development project, Ethiopia

This study deals with investigating the groundwater quality for irrigation purpose, the vulnerability of the aquifer system to pollution and also the aquifer potential for sustainable water resources development in Kobo Valley development project. The groundwater quality is evaluated up on predicting the best possible distribution of hydrogeochemicals using geostatistical method and comparing them with the water quality guidelines given for the purpose of irrigation. The hydro geochemical parameters considered are SAR, EC, TDS, Cl-, Na+, Ca++, SO4 2- and HCO3 -. The spatial variability map reveals that these parameters falls under safe, moderate and severe or increasing problems. In order to present it clearly, the aggregated Water Quality Index (WQI) map is constructed using Weighted Arithmetic Mean method. It is found that Kobo-Gerbi sub basin is suffered from bad water quality for the irrigation purpose. Waja Golesha sub-basin has moderate and Hormat Golena is the better sub basin in terms of water quality. The groundwater vulnerability assessment of the study area is made using the GOD rating system. It is found that the whole area is experiencing moderate to high risk of vulnerability and it is a good warning for proper management of the resource. The high risks of vulnerability are noticed in Hormat Golena and Waja Golesha sub basins. The aquifer potential of the study area is obtained using weighted overlay analysis and 73.3% of the total area is a good site for future water well development. The rest 26.7% of the area is not considered as a good site for spotting groundwater wells. Most of this area fall under Kobo-Gerbi sub basin.

Health-related quality of life in patients with Chagas disease

INTRODUCTION: Chagas disease (ChD) is a chronic illness related to significant morbidity and mortality that can affect the quality of life (QoL) of infected patients. However, there are few studies regarding QoL in ChD. The objectives of this study are to construct a health-related QoL (HRQoL) profile of ChD patients and compare this with a non-ChD (NChD) group to identify factors associated with the worst HRQoL scores in ChD patients. METHODS: HRQoL was investigated in 125 patients with ChD and 21 NChD individuals using the Medical Outcomes Study 36-item Short-Form (SF-36) and the Minnesota Living with Heart Failure Questionnaire (MLWHFQ). Patients were submitted to a standard protocol that included clinical examination, ECG, Holter monitoring, Doppler echocardiogram and autonomic function tests. RESULTS: HRQoL scores were significantly worse among the ChD group compared to the NChD group in the SF-36 domains of physical functioning and role-emotional and in the MLWHFQ scale. For the ChD group, univariate analysis showed that HRQoL score quartiles were associated with level of education, sex, marital status, use of medication, functional classification and cardiovascular and gastrointestinal symptoms. In the multivariate analysis, female sex, fewer years of education, single status, worst functional classification, presence of cardiovascular and gastrointestinal symptoms, associated illnesses, Doppler echocardiographic abnormalities and ventricular arrhythmia detected during Holter monitoring were predictors of lower HRQoL scores. CONCLUSIONS: ChD patients showed worse HRQoL scores compared to NChD. For the ChD group, sociodemographic and clinical variables were associated with worst scores.

Quality of essential drugs in tropical countries: evaluation of antimalarial drugs in the Brazilian Health System

INTRODUCTION: The emergence of drug resistance is one of the main problems concerning malaria treatment. The use of counterfeit and/or substandard antimalarial drugs can contribute to the development of parasite resistance. Thus, the aim of this study was to evaluate the quality of antimalarial drugs distributed in Brazil. METHODS: Samples containing chloroquine phosphate, mefloquine hydrochloride, primaquine phosphate, and quinine sulfate tablets were delivered to the Rio de Janeiro central storeroom (CENADI), state storerooms (SS), and Basic Health Units (BHUs) in the north region of Brazil - a total of 10 sample sets. After 5 months of storage, the samples were collected, and in vitro quality control analyses according to official and published methods were performed. RESULTS: Inadequate drug storage conditions were found in two SS and in all BHUs evaluated. There were no quality deviations found in the chloroquine samples. The quinine samples exhibited weight variation above the allowed limits. The primaquine samples were found to have packaging deficiency. The release of mefloquine in samples from some regions showed a statistically significant difference when compared with the CENADI samples. CONCLUSIONS: It is important to periodically evaluate the quality and storage conditions of essential drugs. The quality deviations found with the primaquine and quinine samples are not related to storage conditions and must be addressed urgently. The decreased mefloquine release from tablets is related to formulation problems or influenced by inadequate storage conditions, prompting further investigation. Even with the mentioned problems, the samples would probably not contribute to resistant parasite selection.

The impact of leprosy on health-related quality of life

INTRODUCTION: Leprosy is a potentially disabling infectious disease that evolves into emotional issues due to the prejudice that persists about the illness. The endemic has declined substantially with multidrug therapy (MDT) in the 80's; however, new demands associated with the reduction of stigma and the improvement of the affected people's quality of life have emerged. In Brazil, leprosy is still a public health problem. Piauí is the second state in the Northeast in prevalence and detection, and Teresina is a hyperendemic city. This study aimed to analyze the health-related quality of life (HRQoL) of people in treatment for leprosy in Teresina/PI. METHODS: An observational study was conducted using the SF-36 (a specific questionnaire for assessing quality of life), which sought the determinants of poor quality of life among people with leprosy, outlining the sociodemographic, clinical, and epidemiological characteristics of the 107 patients interviewed. RESULTS: The correlations between the variables showed five determinants of HRQoL: late diagnosis, multibacillary forms, reactions, disability diagnosis grade II, and prejudice. The profile of the participants showed that leprosy still affects the lower social classes in historically endemic areas, causing high percentages of secondary injuries that compromise the work capacity and quality of life of the affected people, perpetuating the stigma associated with the disease. CONCLUSIONS: The study reinforces the need to implement more effective strategies of disease control, due to the development of severe and disabling forms of leprosy is directly related to poor HRQoL in the same cured patient.

Quality of life of hypertensive and diabetic patients: Who suffers the most?

Objective: Quality of life was measured using the EQ-5D index for Portugal and a Self-Assessed Ranking of Health (SARH) to understand which patients suffer the most decrease in quality of life: diabetics or hypertensive. Method: Using the National Health Survey (NHS), two analyses were conducted on 5649 respondents. The EQ-5D index was calculated by matching questions in the NHS with its dimensions. The SARH was calculated based on a specific question in the NHS. Results: Differences between diseases do not occur using the EQ-5D index. Using the SARH, type 1 diabetics suffer the most while hypertensive suffers the least.

Quality of life of patients with hepatitis C

INTRODUCTION: Self-report on the quality of life (QOL) is increasingly studied in the evaluation of various diseases, especially in chronic ones. However, there are few data in the literature focusing the QOL of patients living with chronic hepatitis C. The objective of this study was to evaluate the QOL in patients with hepatitis C assessed by the World Health Organization Quality of Life Assessment (WHOQOL)-bref scale. METHODS: One hundred and eight hepatitis C patients attending the Outpatient Healthcare Medical Specialties in Tubarão, State of Santa Catarina, Brazil, were contacted from May 2010 to February 2011. Patients answered the WHOQOL-bref scale and a questionnaire about their treatment and risk factors to hepatitis C virus (VHC) infection. RESULTS: Although most of patients with chronic hepatitis C considered their QoL good or very good (58.1%), 47 (44.8%) patients were poorly or very poorly satisfied with their health. About the WHOQOL answers, the environment domain had the highest score (25.15 + 5.77), while the lowest score was the social relationships domain (9.19 + 2.5). There was statistically significant association between household income and quality of life in all domains (p<0.001) and statistically significant association between education and the physical, psychological and social domains of quality of life (p<0.05). CONCLUSIONS: Based on the answers given in WHOQOL-bref, patients with chronic hepatitis C have a generally poor QOL, especially in social relationship domain. Household income and educational level were factors that interfered significantly with patients' QOL assessment.

Performance analysis of an SRI screen based on employment quality in high and low capital industries: International evidence

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

Assessment of microbiological air quality in hemato-oncology units and its relationship with the occurrence of invasive fungal infections: an integrative review

Worldwide aging of the human population has promoted an increase in the incidence of neoplasia, including hematological cancers, which render patients particularly vulnerable to invasive fungal infections. For this reason, air filtration in hemato-oncology units has been recommended. However, scarce literature has assessed the impact of microbiological air quality on the occurrence of fungal infections in this population. We performed an integrative review of studies in the MEDLINE database that were published between January 1980 and October 2012, using the following combinations of keywords: air × quality × HEPA, air × quality × hematology, and airborne fungal infections. The search yielded only 13 articles, suggesting that high-efficiency filtering of the ambient air in hemato-oncology units can prevent the incidence of invasive fungal infections. However, no randomized clinical trial was found to confirm this suggestion. Currently, there is no consensus about the maximum allowable count of fungi in the air, which complicates filtration monitoring, including filter maintenance and replacement, and needs to be addressed in future studies.

Lucuma as an exotic high quality fruit imported into Portugal and the UE

This project has two different goals, one of them is to promote the consumption of exotic fruits with high quality. The other goal of the project is to look for the viability of turning this work project into a real business, focusing in two different channels to diversify its revenues: B2B and B2C. In order to achieve this second goal, this project aims to see the best way to commercialize this product (Lucuma powder and Pulp of Lucuma) and how to make it in an efficient way with right companies. Therefore, the project aims to create a company to commercialize the product between the producers in Peru and possibly small businesses interested in acquire the processed fruit and also individuals interested in own consumption in small quantities. This project, if successful, tries to diversify the consumption into other good organic healthy products in the long-term.

Impact of oral health on health-related quality of life : A cross-sectional study

Background: Despite the consensus regarding the existence of a relationship between “impacts on oral health” and “health-related quality of life”, this relationship, considering the latent nature of these variables, is still poorly investigated. Thus, we performed this study in order to determine the magnitude of the impacts of oral health, demographic and symptom/clinical variables on the health-related quality of life in a Brazilian sample of dental patients. Methods: A total of 1,007 adult subjects enrolled in the School of Dentistry of São Paulo State University (UNESP) - Araraquara Campus for dentistry care between September/2012 and April/2013, participated. 72.4 % were female. The mean age was 45.7 (SD = 12.5) years. The Oral Health Impact Profile (OHIP-14) and the Short Form Health Survey (SF-36) were used. The demographic and symptom/clinical variables collected were gender, age, economic status, presence of pain and chronic disease. The impact of studied variables on health-related quality of life were evaluated with a structural equation model, considering the factor “Health” as the central construct. The fit of the model was first analyzed by the evaluation of the goodness of fit indices (χ 2 /df ≤ 2.0, CFI and TLI ≥ 0.90 and RMSEA < 0.10) and the evaluation of the variables’ impact over health-related quality of life was based on the statistical significance of causal paths (β), evaluated by z tests, for a significance level of 5 %. Results: We observed adequate fit of the model to the data (χ 2 /df = 3.55; CFI = 0.95; TLI = 0.94; RMSEA = 0.05). The impacts on oral health explained 28.0 % of the variability of the health-related quality of life construct, while the total variance explained of the model was 39.0 %. For the demographic and symptom/clinical variables, only age, presence of pain and chronic disease showed significant impacts (p < 0.05). Conclusion: The oral health, age, presence of pain and chronic disease of individuals had significant influence on health-related quality of life.