Administração em saúde : da prestação à avaliação de resultados

A área da “política e administração da saúde”, tem merecido um interesse crescente nas últimas décadas. Provavelmente em consequência do substancial aumento das despesas de saúde que tem ocorrido em todo o mundo mas, também porque se tem verificado uma sensível melhoria da situação de saúde das populações, o que faz com que, “policy makers”, académicos, analistas do setor e “media” tragam as questões de saúde para as primeiras páginas, valorizando-as e tentando melhorar a compreensão sobre o muito complexo processo de prestação em saúde.Não se trata no entanto de uma melhoria que usualmente seja quantificada, ocorrendo até que, se são frequentes, as tentativas de medir os custos e a produção da saúde, setor que tem uma importante dimensão económica, o mesmo não se verifica em relação aos seus resultados (o impacto que os cuidados tiveram na saúde das populações) e ainda menos em relação aos chamados “ganhos em saúde”, afinal o objectivo maior dos sistemas de saúde.Assim, entre a subida das despesas e a melhoria dos resultados, há uma falta de relacionamento que torna difícil fazer um balanço, pelo que é urgente adotar modelos de avaliação da prestação e dos seus resultados que sejam explícitos e ajudem a validar a efetividade da prestação e dos resultados obtidos. O presente trabalho pretende ser um contributo para clarificar esta questão e procurar um indicador corrente que possa ser utilizado para objetivar os “ganhos em saúde” e que, por ser quantificável, possa permitir a definição de medidas de efetividade dos resultados obtidos e de avaliação da performance dos sistemas de saúde.Não será mais uma medida de medição da produção (outputs) mas que pode resolver muitos problemas de há longos anos, e dar suporte ao confronto recursos/resultados e permitindo avaliar a performance de sistemas de saúde, com consistência face aos seus objectivos e fiabilidade, sendo capaz de detetar as mudanças e de mostrar as diferenças.

Proceedings of the Ninth Annual Conference of the British Association for Biological Anthropology and Osteoarchaeology, Department of Archaeology, University of Reading

The Proceedings of the Ninth Annual Conference of the British Association for Biological Anthropology and Osteoarchaeology (BABAO) held at the University of Reading in 2007. Contents: 1) A life course perspective of growing up in medieval London: evidence of sub-adult health from St Mary Spital (London) (Rebecca Redfern and Don Walker); 2) Preservation of non-adult long bones from an almshouse cemetery in the United States dating to the late nineteenth to the early twentieth centuries (Colleen Milligan, Jessica Zotcavage and Norman Sullivan); 3) Childhood oral health: dental palaeopathology of Kellis 2, Dakhleh, Egypt. A preliminary investigation (Stephanie Shukrum and JE Molto); 4) Skeletal manifestation of non-adult scurvy from early medieval Northumbria: the Black Gate cemetery, Newcastle-upon-Tyne (Diana Mahoney-Swales and Pia Nystrom); 5) Infantile cortical hyperostosis: cases, causes and contradictions (Mary Lewis and Rebecca Gowland); 6) Biological Anthropology Tuberculosis of the hip in the Victorian Britain (Benjamin Clarke and Piers Mitchell); 7) The re-analysis of Iron Age human skeletal material from Winnall Down (Justine Tracey); 8) Can we estimate post-mortem interval from an individual body part? A field study using sus scrofa (Branka Franicevec and Robert Pastor); 9) The expression of asymmetry in hand bones from the medieval cemetery at Écija, Spain (Lisa Cashmore and Sonia Zakrezewski); 10) Returning remains: a curator’s view (Quinton Carroll); 11) Authority and decision making over British human remains: issues and challenges (Piotr Bienkowski and Malcolm Chapman); 12) Ethical dimensions of reburial, retention and repatriation of archaeological human remains: a British perspective (Simon Mays and Martin Smith); 13) The problem of provenace: inaccuracies, changes and misconceptions (Margaret Clegg); 14) Native American human remains in UK collections: implications of NAGPRA to consultation, repatriation, and policy development (Myra J Giesen); 15) Repatriation – a view from the receiving end: New Zealand (Nancy Tayles).

Investment in preventing and preparing for biological emergencies and disasters: social and economic costs of disasters versus costs of surveillance and response preparedness

Biological emergencies such as the appearance of an exotic transboundary or emerging disease can become disasters. The question that faces Veterinary Services in developing countries is how to balance resources dedicated to active insurance measures, such as border control, surveillance, working with the governments of developing countries, and investing in improving veterinary knowledge and tools, with passive measures, such as contingency funds and vaccine banks. There is strong evidence that the animal health situation in developed countries has improved and is relatively stable. In addition, through trade with other countries, developing countries are becoming part of the international animal health system, the status of which is improving, though with occasional setbacks. However, despite these improvements, the risk of a possible biological disaster still remains, and has increased in recent times because of the threat of bioterrorism. This paper suggests that a model that combines decision tree analysis with epidemiology is required to identify critical points in food chains that should be strengthened to reduce the risk of emergencies and prevent emergencies from becoming disasters.

Educational and psychosocial programmes for adolescents with diabetes: approaches, outcomes and cost-effectiveness

Diabetes incurs heavy personal and health system costs. Self-management is required if complications are to be avoided. Adolescents face particular challenges as they learn to take responsibility for their diabetes. A systematic review of educational and psychosocial programmes for adolescents with diabetes was undertaken. This aimed to: identify and categorise the types of programmes that have been evaluated; assess the cost-effectiveness of interventions; identify areas where further research is required. Sixty-two papers were identified and Subjected to a narrative review. Generic programmes focus on knowledge/skills, psychosocial issues, and behaviour/self-management. They result in modest improvements across a range of outcomes but improvements are often not sustained, suggesting a need for continuous support, possibly integrated into normal care. In-hospital education at diagnosis confers few advantages over home treatment. The greatest returns may be obtained by targeting poorly controlled individuals. Few studies addressed resourcing issues and robust cost-effectiveness appraisals are required to identify interventions that generate the greatest returns on expenditure. (C) 2004 Elsevier Ireland Ltd. All rights reserved.

Protocol for a feasibility study of a self help cognitive behavioural therapy resource for the reduction of dental anxiety in young people

Background Childhood dental anxiety is very common, with 10–20 % of children and young people reporting high levels of dental anxiety. It is distressing and has a negative impact on the quality of life of young people and their parents as well as being associated with poor oral health. Affected individuals may develop a lifelong reliance on general anaesthetic or sedation for necessary dental treatment thus requiring the support of specialist dental services. Children and young people with dental anxiety therefore require additional clinical time and can be costly to treat in the long term. The reduction of dental anxiety through the use of effective psychological techniques is, therefore, of high importance. However, there is a lack of high-quality research investigating the impact of cognitive behavioural therapy (CBT) approaches when applied to young people’s dental anxiety. Methods/design The first part of the study will develop a profile of dentally anxious young people using a prospective questionnaire sent to a consecutive sample of 100 young people referred to the Paediatric Dentistry Department, Charles Clifford Dental Hospital, in Sheffield. The second part will involve interviewing a purposive sample of 15–20 dental team members on their perceptions of a CBT self-help resource for dental anxiety, their opinions on whether they might use such a resource with patients, and their willingness to recruit participants to a future randomised controlled trial (RCT) to evaluate the resource. The third part of the study will investigate the most appropriate outcome measures to include in a trial, the acceptability of the resource, and retention and completion rates of treatment with a sample of 60 dentally anxious young people using the CBT resource. Discussion This study will provide information on the profile of dentally anxious young people who could potentially be helped by a guided self-help CBT resource. It will gain the perceptions of dental care team members of guided self-help CBT for dental anxiety in young people and their willingness to recruit participants to a trial. Acceptability of the resource to participants and retention and completion rates will also be investigated to inform a future RCT.

Hard tissue formation adjacent to implants of various size and configuration immediately placed into extraction sockets: an experimental study in dogs

Objectives To evaluate the influence of implant size and configuration on osseointegration in implants immediately placed into extraction sockets. Material and methods Implants were installed immediately into extraction sockets in the mandibles of six Labrador dogs. In the control sites, cylindrical transmucosal implants (3.3 mm diameter) were installed, while in the test sites, larger and conical (root formed, 5 mm diameter) implants were installed. After 4 months of healing, the resorptive patterns of the alveolar crest were evaluated histomorphometrically. Results With one exception, all implants were integrated in mineralized bone, mainly composed of mature lamellar bone. The alveolar crest underwent resorption at the control as well as at the test implants. This resorption was more pronounced at the buccal aspects and significantly greater at the test (2.7 +/- 0.4 mm) than at the control implants (1.5 +/- 0.6 mm). However, the control implants were associated with residual defects that were deeper at the lingual than at the buccal aspects, while these defects were virtually absent at test implants. Conclusions The installment of root formed wide implants immediately into extraction sockets will not prevent the resorption of the alveolar crest. In contrast, this resorption is more marked both at the buccal and lingual aspects of root formed wide than at standard cylindrical implants. To cite this article:Caneva M, Salata LA, de Souza SS, Bressan E, Botticelli D, Lang NP. Hard tissue formation adjacent to implants of various size and configuration immediately placed into extraction sockets: an experimental study in dogs.Clin. Oral Impl. Res. 21, 2010; 885-895.doi: 10.1111/j.1600-0501.2010.01931.x.

Balancing the role of the dental school in teaching, research and patient care; including care for underserved areas

Inequalities within dentistry are common and are reflected in wide differences in the levels of oral health and the standard of care available both within and between countries and communities. Furthermore there are patients, particularly those with special treatment needs, who do not have the same access to dental services as the general public. The dental school should aim to recruit students from varied backgrounds into all areas covered by the oral healthcare team and to train students to treat the full spectrum of patients including those with special needs. It is essential, however, that the dental student achieves a high standard of clinical competence and this cannot be gained by treating only those patients with low expectations for care. Balancing these aspects of clinical education is difficult. Research is an important stimulus to better teaching and better clinical care. It is recognized that dental school staff should be active in research, teaching, clinical work and frequently administration. Maintaining a balance between the commitments to clinical care, teaching and research while also taking account of underserved areas in each of these categories is a difficult challenge but one that has to be met to a high degree in a successful, modern dental school.

Exploratory factor analysis of the Brazilian OHIP for edentulous subjects

P>The use of seven domains for the Oral Health Impact Profile (OHIP)-EDENT was not supported for its Brazilian version, making data interpretation in clinical settings difficult. Thus, the aim of this study was to assess patients` responses for the translated OHIP-EDENT in a group of edentulous subjects and to develop factor scales for application in future studies. Data from 103 conventional and implant-retained complete denture wearers (36 men, mean age of 69 center dot 1 +/- 10 center dot 3 years) were assessed using the Brazilian version of the OHIP-EDENT. Oral health-related quality of life domains were identified by factor analysis using principal component analysis as the extraction method, followed by varimax rotation. Factor analysis identified four factors that accounted for 63% of the 19 items total variance, named masticatory discomfort and disability (four items), psychological discomfort and disability (five items), social disability (five items) and oral pain and discomfort (five items). Four factors/domains of the Brazilian OHIP-EDENT version represent patient-important aspects of oral health-related quality of life.

Inequalities in dental services utilization among Brazilian low-income children: the role of individual determinants

Objectives: To assess the role of the individual determinants on the inequalities of dental services utilization among low-income children living in the working area of Brazilian`s federal Primary Health Care program, which is called Family Health Program (FHP), in a big city in Southern Brazil. Methods: A cross-sectional population-based study was performed. The sample included 350 children, ages 0 to 14 years, whose parents answered a questionnaire about their socioeconomic conditions, perceived needs, oral hygiene habits, and access to dental services. The data analysis was performed according to a conceptual framework based on Andersen`s behavioral model of health services use. Multivariate models of logistic regression analysis instructed the hypothesis on covariates for never having had a dental visit. Results: Thirty one percent of the surveyed children had never had a dental visit. In the bivariate analysis, higher proportion of children who had never had a dental visit was found among the very young, those with inadequate oral hygiene habits, those without perceived need of dental care, and those whose family homes were under absent ownership. The mechanisms of social support showed to be important enabling factors: children attending schools/kindergartens and being regularly monitored by the FHP teams had higher odds of having gone to the dentist, even after adjusting for socioeconomic, demographic, and need variables. Conclusions: The conceptual framework has confirmed the presence of social and psychosocial inequalities on the utilization pattern of dental services for low-income children. The individual determinants seem to be important predictors of access.

Untreated dental caries in children with cerebral palsy in the Brazilian context

Objectives. To assess the prevalence of untreated dental caries in children with cerebral palsy and to assess socio-demographic, behavioural, and clinical covariates. Design. Cross-sectional assessment of 200 children and adolescents with cerebral palsy (2-17 years old) enrolled in a specialized healthcare unit in Sao Paulo, Brazil. The dental examination followed the World Health Organization`s guidelines for oral health surveys; familial caretakers informed on socio-economic status and behaviour; the patient`s medical record informed their clinical status. Results. The proportion of children that presented at least one tooth affected by untreated caries was 49.5%. Poor socio-economic standings and a higher frequency of sugar consumption associated with a worse profile of dental health; different types of cerebral palsy (spastic, tetraparesis) did not. The prevalence of untreated caries was higher than reference values assessed for the overall population of the same age range. Conclusions. The high burden of untreated dental caries on cerebral palsy patients reinforces the importance of the dentist in the interdisciplinary healthcare team attending these children. Factors associated with this outcome are the same for the general population; these findings underscore the necessity of implementing effective caries prevention in this population of cerebral palsy children.

Prevalence of untreated caries in deciduous teeth in urban and rural areas in the state of Sao Paulo, Brazil

Objectives. To describe the prevalence of dental caries in children with deciduous teeth in urban and rural areas in the state of Sao Paulo, Brazil, and to identify associated factors. Methods. The study included 24 744 children ( 5 - 7 years of age) examined as part of an epidemiological survey on oral health carried out in the state of Sao Paulo ( Levan-tamento Epidemiologico de Sa de Bucal do Estado de Sao Paulo). Multilevel analysis was used to investigate whether the prevalence of untreated caries was associated with the sociodemographic characteristics of the children examined or with the socioeconomic aspects of the participating cities. Results. Being black or brown ( adjusted odds ratio ( OR) = 1.27), attending school in rural areas ( adjusted OR = 1.88), and attending public school ( adjusted OR = 3.41) were identified as determinants for an increased probability of presenting deciduous teeth with untreated caries. Being a female ( adjusted OR = 0.83) was identified as a protective factor. The negative coefficients obtained for second- level independent variables indicate that the oral health profile of the cities included in the study were positively impacted by a higher municipal human development index ( beta = - 0.47) and fluoridated drinking water ( beta = - 0.32). Conclusions. The prevalence of untreated caries is influenced by individual and sociodemographic factors. The present study provides epidemiological information concerning the rural areas in the state of Sao Paulo. This information is useful for strategic planning and for establishing guidelines for oral health actions in local health systems, thereby contributing to oral health equity.

Caries, gender and socio-economic change in the Xavante Indians from Central Brazil

Background: The oral health conditions of indigenous peoples in Amazonia are closely associated with ecological and dietary changes related to interaction with non-Indians. Aim: The study investigated the incidence of caries in an indigenous community from Central Brazil focusing on gender differences. Subjects and methods: The research was conducted among the Xavante Indians and was based on longitudinal data collected in two surveys (1999 and 2004). The study included 128 individuals, 63 (49.2%) males and 65 (50.8%) females, divided in four age brackets (6-12, 13-19, 20-34, 35-60 years of age). The DMFT (decayed, missing and filled teeth) index and incidences (difference between 1999 and 2004) were calculated for each individual. The proportion of incidence was also calculated. Differences in caries risk between gender and age brackets were compared by parametric and non-parametric tests. Results: There were statistically significant differences in relation to caries incidence between age brackets and gender. The greatest incidence was observed in the 20-34 age bracket, which presented 3.30 new decayed teeth, twice the risk of the 6-12 age bracket (p0.01), chosen as reference. While females in most age groups did not show higher risk for caries when compared to males, there was a 4.04-fold risk in the 20-34 age bracket (p0.01). Conclusion: It is concluded that factors related to the social functions of each sex (gender issues) and differential access to information, health services, and education may help to understand the differences observed in the incidence of caries.

A prospective 12-month study of the effect of smoking cessation on periodontal clinical parameters

P>Aim The aim of this 12-month prospective study was to assess the adjunctive effect of smoking cessation in non-surgical periodontal therapy of subjects with severe chronic periodontitis. Materials and methods Of the 201 subjects enrolled from a smoking cessation clinic, 93 were eligible and received non-surgical periodontal treatment and concurrent smoking cessation treatment. Periodontal maintenance was performed every 3 months. Full-mouth periodontal examination in six sites per tooth was performed by a calibrated examiner, blinded to smoking status, at baseline, 3, 6 and 12 months after non-surgical periodontal treatment. Furthermore, expired air carbon monoxide concentration measurements and interviews based on a structured questionnaire were performed in order to collect demographic and smoking data. Results Of the 93 eligible subjects, 52 remained in the study after 1 year. Of these, 17 quit smoking and 35 continued smoking or oscillated. After 1 year, only quitters presented significant clinical attachment gain (p=0.04). However, there were no differences between the groups regarding clinical attachment level, probing depth, bleeding on probing and plaque index after 1 year (p > 0.05). Conclusion Smoking cessation promoted clinical attachment gain in chronic periodontitis subjects from a smoking cessation clinic after 1 year of follow-up.

Evaluating microfossil content of dental calculus from Brazilian sambaquis

To date, limited numbers of dental calculus samples have been analyzed by researchers in diverse parts of the world. The combined analyses of these have provided some general guidelines for the analysis of calculus that is non-destructive to archaeological teeth. There is still a need for a quantitative study of large numbers of calculus samples to establish protocols, assess the level of contamination, evaluate the quantity of microfossils in dental calculus, and to compare analysis results with the literature concerning the biology of calculus formation. We analyzed dental calculus from 53 teeth from four Brazilian sambaquis. Sambaquis are the shell-mounds that were established prehistorically along the Brazilian coast. The analysis of sambaqui dental calculi shows that there are relatively high concentrations of microfossils (phytoliths and starch), mineral fragments, and charcoal in dental calculus. Mineral fragments and charcoal are possibly contaminants. The largest dental calculi have the lowest concentrations of microfossils. Biologically, this is explained by individual variation in calculus formation between people. Importantly, starch is ubiquitous in dental calculus. The starch and phytoliths show that certainly Dioscorea (yam) and Araucaria angustifolia (Parana pine) were eaten by sambaqui people. Araceae (arum family), Ipomoea batatas (sweet potato) and Zea mays (maize) were probably in their diet. (C) 2009 Elsevier Ltd. All rights reserved.