RESUMO

BACKGROUND: The prognostic significance of heart rate (HR) and its relationship with beta-blocker use are controversial and have never been evaluated in resistant hypertension. METHODS: In a prospective study, 528 patients with resistant hypertension had HR measured on clinical examination, electrocardiography (ECG), and during ambulatory blood pressure monitoring. Primary endpoints were a composite of fatal and nonfatal cardiovascular events, all-cause and cardiovascular mortality. Multivariable Cox regression was used to assess the associations between slow HR (< 60 bpm or < 55 bpm for nighttime HR) and fast HR (> 75 bpm or > 70 bpm for nighttime HR) and the occurrence of endpoints in relation to the reference middle HR (60-75 bpm) subgroup. RESULTS: After a median follow-up of 4.8 years, 62 patients died, 44 from cardiovascular causes; and 94 cardiovascular events occurred. Fast and slow HRs were mainly predictors of mortality, and ambulatory HRs were more significant risk markers than clinic or ECG HR. A slow 24-hour HR was a predictor of the composite endpoint (hazard ratio, 2.0; 95% confidence interval [CI], 1.2-3.4), whereas both slow and fast ambulatory HRs were predictors of cardiovascular mortality (hazard ratio, 2.3; 95% CI, 1.1-5.1). Four hundred and seventeen patients (79%) were using beta-blockers and this affected the HR prognostic value. A fast HR was a more significant risk marker in patients using beta-blockers, whereas a slow HR was a predictor mainly in those not using beta-blockers. CONCLUSIONS: There is an overall U-shaped relationship between HRs, particularly when measured during ambulatory monitoring, and prognosis in resistant hypertension. A fast HR is a significant predictor in patients using beta-blockers, while a slow heart rate is a more important predictor in those not using beta-blockers.

Assuntos

Antagonistas Adrenérgicos beta/uso terapêutico , Frequência Cardíaca/fisiologia , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Idoso , Pressão Sanguínea/fisiologia , Doenças Cardiovasculares/epidemiologia , Estudos de Coortes , Eletrocardiografia , Feminino , Seguimentos , Humanos , Hipertensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco

RESUMO

Resistant hypertension is defined as uncontrolled office blood pressure, despite the use of ≥3 antihypertensive drugs. Ambulatory blood pressure monitoring (ABPM) is mandatory to diagnose 2 different groups, those with true and white-coat resistant hypertension. Patients are found to change categories between controlled/uncontrolled ambulatory pressures without changing their office blood pressures. In this way, ABPM should be periodically repeated. The aim of this study was to evaluate the most appropriate time interval to repeat ABPM to assure sustained blood pressure control in patients with white-coat resistant hypertension. This prospective study enrolled 198 patients (69% women; mean age: 68.9±9.9 years) diagnosed as white-coat resistant hypertension on ABPM. Patients were submitted to a second confirmatory examination 3 months later and repeated twice at 6-month intervals. Statistical analyses included Bland-Altman repeatability coefficients and multivariate logistic regression. Mean office blood pressure was 163±20/84±17 mm Hg, and mean 24-hour blood pressure was 118±8/66±7 mm Hg. White-coat resistant hypertension diagnosis presented a moderate reproducibility and was confirmed in 144 patients after 3 months. In the third and fourth ABPMs, 74% and 79% of patients sustained the diagnosis. In multivariate regression, a daytime systolic blood pressure ≤115 mm Hg in the confirmatory ABPM triplicated the chance of white-coat resistant hypertension status persistence after 1 year. In conclusion, a confirmatory ABPM is necessary after 3 months of the first white-coat-resistant hypertension diagnosis, and the procedure should be repeated at 6-month intervals, except in patients with daytime systolic blood pressure ≤115 mm Hg, in whom it may be repeated annually.

Assuntos

Monitorização Ambulatorial da Pressão Arterial , Pressão Sanguínea/fisiologia , Hipertensão do Jaleco Branco/diagnóstico , Hipertensão do Jaleco Branco/fisiopatologia , Idoso , Algoritmos , Anti-Hipertensivos/uso terapêutico , Estudos de Coortes , Feminino , Humanos , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Tempo , Hipertensão do Jaleco Branco/tratamento farmacológico

RESUMO

OBJECTIVE: The prognostic importance of a reduced glomerular filtration rate (GFR) is unsettled in resistant hypertension. The aim was to evaluate GFR and its interaction with microalbuminuria as prognostic predictors in resistant hypertensive patients. METHODS: In a prospective study, 531 resistant hypertensive patients had albuminuria measured and GFR estimated by Cockroft-Gault (eGFRCG) and Modification of Diet in Renal Disease (MDRD; eGFRMDRD) equations. Primary endpoints were a composite of fatal and nonfatal cardiovascular events, all-cause and cardiovascular mortality. Multiple Cox regression assessed the associations between reduced GFR and endpoints, and interaction with microalbuminuria. RESULTS: After a median follow-up of 4.9 years, 72 patients died, 42 from cardiovascular causes; and 96 cardiovascular events occurred. Decreasing grades of eGFRMDRD were predictors of the composite endpoint with hazard ratios of 2.1 [95% confidence interval (CI) 1.1-3.8], 2.2 (1.2-3.9) and 3.5 (1.4-8.7) for the subgroups with eGFR between 60-89, 30-59 and less than 30 mg/min per 1.73 m, respectively. A decreased eGFRCG was predictive of the composite endpoint only in the lowest GFR subgroup (hazard ratio 2.7, 95% CI 1.0-7.1). The lowest eGFR subgroups were also associated with all-cause mortality, regardless of the estimated equation used. The presence of both reduced eGFR and microalbuminuria significantly increased cardiovascular risk in relation to one or another isolated, with hazard ratios of 3.0 (1.7-5.3), 2.9 (1.5-5.5) and 4.6 (2.2-10.0), respectively for the composite endpoint, all-cause and cardiovascular mortality. CONCLUSION: A reduced GFR, mainly estimated by the MDRD equation, is an independent predictor of increased cardiovascular morbidity and mortality in resistant hypertension. The combination of a reduced GFR and increased albuminuria identifies patients with a very high cardiovascular risk.

Assuntos

Albuminúria/complicações , Albuminúria/fisiopatologia , Taxa de Filtração Glomerular , Hipertensão/complicações , Hipertensão/fisiopatologia , Idoso , Anti-Hipertensivos/uso terapêutico , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/fisiopatologia , Estudos de Coortes , Intervalo Livre de Doença , Resistência a Medicamentos , Feminino , Humanos , Hipertensão/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos

RESUMO

OBJECTIVE: The prognostic value of microalbuminuria is unsettled in resistant hypertension. The objective was to evaluate the importance of baseline and serial changes in albuminuria as predictors of cardiovascular morbidity and mortality in patients with resistant hypertension. METHODS: 531 resistant hypertensives had urinary albumin excretion rate (UAER) measured prospectively at baseline and at the 2nd year of follow-up. Primary endpoints were a composite of fatal and non-fatal cardiovascular events, all-cause and cardiovascular mortalities. Total strokes and coronary heart disease (CHD) events were secondary endpoints. Multiple Cox regression assessed the associations between UAER and endpoints. RESULTS: After a median follow-up of 4.9 years, 72 patients died, 42 from cardiovascular causes; 96 cardiovascular events occurred, 42 strokes and 47 CHD events. After adjustment for several cardiovascular risk factors, baseline UAER, either analyzed as a continuous variable or dichotomized at different cut-off values, was an independent predictor of the composite endpoint, all-cause and cardiovascular mortality, strokes and CHD events. Each 10-fold increase in UAER implied a significant 1.6, 1.5, 2.0, 1.5 and 1.6-fold higher risk, respectively, for each of the above endpoints. Serial changes in microalbuminuria status during follow-up tended to parallel changes in cardiovascular risk, regression of microalbuminuria was associated with a 27% lower risk and development with a 65% higher risk of having a cardiovascular event. CONCLUSIONS: Baseline albuminuria strongly predicts cardiovascular morbidity and mortality in resistant hypertensive patients and serial changes in microalbuminuria may translate into changes in risk. Microalbuminuria reduction may be a goal of anti-hypertensive treatment.

Assuntos

Albuminúria/etiologia , Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Doenças Cardiovasculares/etiologia , Resistência a Medicamentos , Hipertensão/tratamento farmacológico , Idoso , Albuminúria/mortalidade , Análise de Variância , Brasil/epidemiologia , Doenças Cardiovasculares/patologia , Distribuição de Qui-Quadrado , Feminino , Humanos , Hipertensão/complicações , Hipertensão/mortalidade , Hipertensão/fisiopatologia , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo

RESUMO

Objetivo: medir o desempenho de hospitais de ensino por Análise Envoltória de Dados (Data Envelopment Analysis – DEA) e estudar a influência de fatores ambientais na eficiência encontrada. Metodologia: foram analisados 104 hospitais de ensino e o escore de eficiência foi gerado por DEA, modelo VRS, orientado a out put, com restrição aos pesos. Em uma segunda etapa, utilizou-se regressão linear logística, usando-se o escore de eficiência DEA como variável dependente. Resultados: a média de eficiência foi 49 por cento (DP=26 por cento); cinco hospitais foram considerados eficientes. Na regressão, as variáveis com maior poder explicativo para eficiência foram porte hospitalar (p=0,001), alta intensidade (p=0,027) e baixa dedicação (p=0,006) de ensino. Não foi verificada associação entre eficiência e natureza jurídica ou IDH do município de entorno. Conclusão: a eficiência hospitalar é influenciada por variáveis ambientais, nem todas suscetíveis à governabilidade do gestor, que podem ser consideradas na pactuação de metas para financiamento.

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Objective: to measure the performance of teaching hospitals by Data Envelopment Analysis (DEA) and to study the influence of environmental factors on the efficiency. Methodology: A hundred and four teaching hospitals were analyzed and the efficiency score was generated by DEA, VRS model, output oriented, with weight restrictions. The efficiency scorecriteria were then regressed on non-discretionary variables by logistic linear regression. Results: the efficiency score mean was 49 per cent (SD=26 per cent); five hospitals were efficient. In logistic regression, the main predictors of efficiency were the size of the hospital (p=0.001), high teaching intensity (p=0.027) and low teaching dedication (p=0.006). There was no association between efficiency and ownership form or HDI of the surrounding municipality. Conclusion: hospital efficiency suffers the influence of different environmental factors, not necessarily under the control of the manager, that should be considered when defining administrative goals and financing pacts.

Assuntos

Humanos , Eficiência , Hospitais de Ensino/normas , Modelos Logísticos

RESUMO

OBJECTIVE: To assess the performance and integration between the health care and teaching dimensions in Brazilian university hospitals. METHODS: A network data envelopment analysis (DEA) model was designed to measure the performance of federal university hospitals, which enables the relationship between the teaching and health care dimensions to be considered simultaneously. Data from the Ministry of Education Information System of University Hospitals, in the second semester of 2003, were used. Results of the network model were compared to those of classical DEA models to assess the advantages of the new methodological proposal. RESULTS: The efficiency of the hospitals assessed varied between 0.19 and 1.00 (mean = 0.54). The dimensional score showed that hospitals prioritize the gain in health care efficiency. It was observed that there was a need to double the number of medical students and increase the number of residents by 14% to obtain efficiency in the teaching dimension. CONCLUSIONS: The model was useful for both unit managers, aiming to integrate teaching and health care, and regulatory organizations, when defining policies and incentives.

Assuntos

Atenção à Saúde/normas , Eficiência Organizacional/normas , Hospitais Universitários/normas , Ensino/normas , Brasil , Humanos , Garantia da Qualidade dos Cuidados de Saúde/métodos

RESUMO

OBJETIVO: Avaliar o desempenho e a integração entre as dimensões de assistência e de ensino dos hospitais universitários brasileiros. MÉTODOS: Um modelo de data envelopment analysis em redes (network DEA) foi elaborado para aferir o desempenho de hospitais universitários federais, o qual permite considerar a relação entre as dimensões de ensino e de assistência, simultaneamente. Foram utilizados os dados do Sistema de Informação dos Hospitais Universitários do Ministério da Educação, referentes ao segundo semestre de 2003, e os resultados do modelo network foram comparados àqueles dos modelos DEA tradicionais para avaliação das vantagens da nova proposta metodológica. RESULTADOS: A eficiência dos hospitais avaliados variou entre 0,19 e 1,00 (média = 0,54)...

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OBJECTIVE: To assess the performance and integration between the health care and teaching dimensions in Brazilian university hospitals. METHODS: A network data envelopment analysis (DEA) model was designed to measure the performance of federal university hospitals, which enables the relationship between the teaching and health care dimensions to be considered simultaneously. Data from the Ministry of Education Information System of University Hospitals, in the second semester of 2003, were used. Results of the network model were compared to those of classical DEA models to assess the advantages of the new methodological proposal. RESULTS: The efficiency of the hospitals assessed varied between 0.19 and 1.00 (mean = 0.54)...

Assuntos

Humanos , Atenção à Saúde/normas , Eficiência Organizacional/normas , Hospitais Universitários/normas , Ensino/normas , Brasil , Garantia da Qualidade dos Cuidados de Saúde/métodos

RESUMO

OBJECTIVES: The prognostic importance of serial changes in electrocardiographic strain pattern of lateral ST-depression and T-wave inversion is unclear. The objective was to evaluate the significance of baseline and serial changes in strain pattern as predictors of cardiovascular morbidity and mortality in patients with resistant hypertension. METHODS: At baseline and during follow-up, 532 resistant hypertensive patients had the presence of strain pattern examined on 12-lead ECGs. Other clinical laboratory, echocardiographic and ambulatory blood pressure data were obtained. Primary endpoints were a composite of total cardiovascular events and mortality. Strokes and coronary heart disease events were secondary endpoints. Multiple Cox regression assessed the associations between strain pattern and subsequent endpoints. RESULTS: At baseline, 115 patients (21.6%) presented the strain pattern and during follow-up, 17 patients regressed and 22 developed new strain pattern. After a median follow-up of 4.8 years, 69 patients died, 46 from cardiovascular causes; and 107 cardiovascular events occurred, 44 strokes and 42 coronary heart disease events. After adjustment for several cardiovascular risk factors, including time-varying ambulatory blood pressures and electrocardiographic voltage criteria of left ventricular hypertrophy, the persistence or development of strain during follow-up was a predictor of the composite endpoint (hazard ratio 1.97, 95% confidence interval 1.19-3.25), all-cause mortality (hazard ratio 1.99, 95% confidence interval 1.10-3.61) and of stroke (hazard ratio 3.09, 95% confidence interval 1.40-6.81). The combination of strain pattern and left ventricular hypertrophy voltage criteria improved stratification of cardiovascular risk. CONCLUSION: Serial changes in electrocardiographic strain pattern during follow-up predict cardiovascular morbidity and mortality in resistant hypertensive patients. Regression or prevention of the strain pattern during antihypertensive treatment may be a therapeutic goal to improve prognosis.

Assuntos

Doença das Coronárias/fisiopatologia , Ecocardiografia sob Estresse , Hipertensão/fisiopatologia , Hipertrofia Ventricular Esquerda/fisiopatologia , Acidente Vascular Cerebral/fisiopatologia , Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea , Brasil/epidemiologia , Doença das Coronárias/mortalidade , Progressão da Doença , Resistência a Medicamentos , Hipertensão/tratamento farmacológico , Hipertensão/mortalidade , Hipertrofia Ventricular Esquerda/mortalidade , Prognóstico , Acidente Vascular Cerebral/mortalidade , Taxa de Sobrevida

RESUMO

The role of spironolactone in resistant hypertension management is unclear. The aim of this prospective trial was to evaluate the antihypertensive effect of spironolactone in patients with true resistant hypertension diagnosed by ambulatory blood pressure monitoring. A total of 175 patients had clinical and complementary exams obtained at baseline and received spironolactone in doses of 25 to 100 mg/d. A second ambulatory blood pressure monitoring was performed after a median interval of 7 months. Paired Student t test was used to assess differences in blood pressure before and during spironolactone administration, and multivariate analysis adjusted for age, sex, and number of antihypertensive drugs to assess the predictors of blood pressure fall. There were mean reductions of 16 and 9 mm Hg, respectively, in 24-hour systolic and diastolic blood pressures (95% CIs: 13 to 18 and 7 to 10 mm Hg; P<0.001). Office systolic blood pressure and diastolic blood pressure also decreased (14 and 7 mm Hg). Controlled ambulatory blood pressure was reached in 48% of patients. Factors associated with better response were higher waist circumference, lower aortic pulse wave velocity, and lower serum potassium. No association with plasma aldosterone or aldosterone:renin ratio was found. Adverse effects were observed in 13 patients (7.4%). A third ambulatory blood pressure monitoring performed in 78 patients after a median of 15 months confirmed the persistence of the spironolactone effect. In conclusion, spironolactone administration to true resistant hypertensive patients is safe and effective in decreasing blood pressure, especially in those with abdominal obesity and lower arterial stiffness. Its addition to an antihypertensive regimen as the fourth or fifth drug is recommended.

Assuntos

Pressão Sanguínea/efeitos dos fármacos , Hipertensão/tratamento farmacológico , Espironolactona/uso terapêutico , Monitorização Ambulatorial da Pressão Arterial , Doenças Mamárias/induzido quimicamente , Diuréticos/efeitos adversos , Diuréticos/uso terapêutico , Seguimentos , Ginecomastia/induzido quimicamente , Humanos , Hipertensão/fisiopatologia , Modelos Lineares , Análise Multivariada , Estudos Prospectivos , Espironolactona/efeitos adversos , Resultado do Tratamento

RESUMO

Increased arterial stiffness may be causally related to resistant hypertension. Our objective was to investigate the variables, particularly those derived from ambulatory blood pressure (BP) monitoring (ABPM), associated with increased aortic stiffness in resistant hypertensives. In a cross-sectional study, 600 resistant hypertensive patients without peripheral arterial disease were evaluated. Arterial stiffness was assessed by aortic pulse wave velocity (PWV), and was considered increased if >12 m s(-1). Statistical analyses included multiple linear and logistic regressions to assess the independent correlates of increased aortic stiffness. One hundred and sixty-eight patients (28%) had aortic PWV >12 m s(-1). Patients with increased PWV were older and had a higher prevalence of cardiovascular risk factors than did those patients with low PWV. On ABPM, patients with elevated PWV had higher daytime and night time systolic BP (SBP) and pulse pressures (PP), less nocturnal decrease in SBP and a higher prevalence of non-dipping pattern. On multiple linear regression, the independently associated variables with aortic PWV were age (P<0.001), 24-h PP (P<0.001), high-density lipoprotein (HDL)-cholesterol (P<0.001), microalbuminuria (P<0.001), fasting glycemia (P=0.001) and a decrease in nocturnal SBP (P=0.002). Multivariate logistic regression confirmed these results, with the non-dipping patients having a 72% higher likelihood of presenting with increased aortic stiffness (95% confidence interval: 1.12-2.65, P=0.013). This association was observed in both the reduced and reverted dipping patterns, but not in the extreme dipping pattern. In conclusion, a blunted nocturnal decrease in BP is independently associated with increased aortic stiffness in resistant hypertensive patients. Other independent correlates are older age, diabetes, microalbuminuria, low HDL-cholesterol and a widened 24-h PP.

Assuntos

Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/fisiologia , Hipertensão/patologia , Idoso , Aorta/patologia , Monitorização Ambulatorial da Pressão Arterial , Colesterol/sangue , Ritmo Circadiano , Estudos Transversais , Resistência a Medicamentos , Feminino , Humanos , Hipertensão/tratamento farmacológico , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Prognóstico

RESUMO

The ambulatory arterial stiffness index (AASI) is a recently proposed index derived from 24-h ambulatory blood pressure monitoring (ABPM) for the evaluation of arterial stiffness. In this cross-sectional study we investigated whether AASI reflects arterial stiffness in patients with resistant hypertension by comparing AASI and ambulatory pulse pressure (PP) with aortic pulse wave velocity (PWV), a measure of arterial stiffness, in 391 resistant hypertensives. Clinical, laboratory and echocardiographic variables, 24-h ABPM and aortic PWV (measured using the Complior device) were obtained. AASI was calculated as 1--the regression slope of 24-h diastolic on systolic blood pressure (BP). Statistical analysis involved single and multiple linear regressions to assess the correlations between the two ABPM variables and PWV, both unadjusted and adjusted for potential confounders (age, gender, body height, presence of diabetes, 24-h mean arterial pressure [MAP], heart rate, and nocturnal BP reduction). Ambulatory PP and aortic PWV were independently associated with age, gender, presence of diabetes, and 24-h MAP, whereas AASI was associated with age, diabetes, and nocturnal diastolic BP reduction. PP showed stronger unadjusted (r=0.39, p<0.001) and adjusted (r=0.22, p<0.001) correlations with aortic PWV than AASI (r=0.12, p=0.032 and r= -0.04, p=0.47, respectively). In the analysis of subgroups stratified by gender, age, presence of atherosclerotic diseases and diabetes, dipping pattern, and ambulatory BP control, the superiority of PP over AASI was apparent in all subgroups. In conclusion, 24-h ambulatory PP was better correlated to arterial stiffness, as evaluated by aortic PWV, than the novel AASI, in patients with resistant hypertension.

Assuntos

Monitorização Ambulatorial da Pressão Arterial , Pressão Sanguínea , Hipertensão/diagnóstico , Hipertensão/fisiopatologia , Fluxo Pulsátil , Idoso , Aorta/diagnóstico por imagem , Aorta/fisiologia , Doenças da Aorta/diagnóstico , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/fisiopatologia , Estudos Transversais , Feminino , Humanos , Hipertensão/diagnóstico por imagem , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Ultrassonografia

RESUMO

In order to demonstrate how DEA modeling can be helpful for hospital performance assessments conducted in compliance with Brazil's Teaching Hospital Policy, a case study is presented of 31 general hospitals linked to Federal Universities. It considers data on assistance, teaching and research and the use of the IDEAL (Interactive Data Envelopment Analysis Laboratory) software as a tool for assessing their efficiency. Developed in Brazil, this unique software provides a three-dimensional view of the productivity frontier, for easier exploratory analyses and selection of pertinent variables, with a better understanding of the outputs of the model (multiplier and envelope) for specialists and decision-makers. As an example, a University Hospital benchmark is presented through outputs that take structural and regional input differences into consideration. This modeling also indicates the changes required in the inefficient units (alterations to input and/or /output vectors), setting forth recommendations on public financing based on quality/efficiency.

Assuntos

Estudos de Avaliação como Assunto , Hospitais de Ensino/normas , Brasil

RESUMO

De modo a demonstrar como a modelagem por Análise Envoltória de Dados (DEA) permite aferir o desempenho dos hospitais e subsidiar a avaliação da implantação da Política de Reestruturação dos Hospitais de Ensino, desenvolve-se um estudo de caso com os 31 hospitais gerais pertencentes a universidades federais brasileiras. Consideram-se indicadores de assistência, ensino e pesquisa e utiliza-se o programa IDEAL (Interactive Data Envelopment Analysis Laboratory) como ferramenta de avaliação de desempenho. O IDEAL, desenvolvido no país, é o único no mundo capaz de prover a visualização tridimensional da fronteira de produtividade, facilitando a análise exploratória e escolha das variáveis pertinentes, assim como a compreensão dos resultados do modelo (multiplicador e envelope) pelo especialista e decisor. A título de exemplo, é apresentado o benchmark dos hospitais universitários por meio de indicadores de resultado (outputs), que consideram as diferenças estruturais e/ou as demandas regionais (inputs). A modelagem também permite indicar as mudanças necessárias para as unidades ineficientes (alterações nos vetores de inputs e/ou outputs) e gerar recomendações sobre a distribuição dos recursos públicos baseada em qualidade/eficiência.

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In order to demonstrate how DEA modeling can be helpful for hospital performance assessments conducted in compliance with Brazil's Teaching Hospital Policy, a case study is presented of 31 general hospitals linked to Federal Universities. It considers data on assistance, teaching and research and the use of the IDEAL (Interactive Data Envelopment Analysis Laboratory) software as a tool for assessing their efficiency. Developed in Brazil, this unique software provides a three-dimensional view of the productivity frontier, for easier exploratory analyses and selection of pertinent variables, with a better understanding of the outputs of the model (multiplier and envelope) for specialists and decision-makers. As an example, a University Hospital benchmark is presented through outputs that take structural and regional input differences into consideration. This modeling also indicates the changes required in the inefficient units (alterations to input and/or /output vectors), setting forth recommendations on public financing based on quality/efficiency.

Assuntos

Estudos de Avaliação como Assunto , Hospitais de Ensino/normas , Brasil

RESUMO

The relation between left ventricular hypertrophy (LVH) and unfavorable cardiovascular prognosis may involve systemic inflammation and endothelial dysfunction/damage. The aim of this study was to investigate in a cross-sectional design the relationships of LVH with C-reactive protein (CRP) levels (a marker of systemic low-grade inflammation) and with microalbuminuria (a marker of glomerular endothelial damage) in 705 patients with resistant hypertension. At baseline, all were submitted to a laboratory evaluation including 24-hour urinary albumin excretion, 2D echocardiogram, and 24-hour ambulatory blood pressure monitoring. A total of 463 patients also had high-sensitivity CRP levels determined. LVH was defined as an indexed left ventricular mass >110 g/m(2) in women and >125 g/m(2) in men. Microalbuminuria was evaluated in 3 categories: low normal (<15 mg/24 hours), high normal (between 15 and 29 mg/24 hours), and abnormal (between 30 and 299 mg/24 hours). CRP was dichotomized at the median value (3.7 mg/L). Associations with LVH were examined after adjustment for all of the potential confounders by multivariate logistic regression. A total of 534 patients (75.7%) had LVH. After full adjustment, both abnormal microalbuminuria (odds ratio: 1.97; 95% CI: 1.04 to 3.73) and high CRP (OR: 1.76; 95% CI: 1.06 to 2.93) were independently associated with LVH occurrence. The high-normal albuminuria was associated with a borderline significant 46% increased chance of having LVH. Furthermore, the association between high CRP and LVH was observed exclusively in the subgroup with normal albuminuria. In conclusion, both systemic inflammation and endothelial damage were associated with LVH occurrence. These relationships offer insight into the pathophysiological mechanisms linking LVH to atherosclerosis and to increased cardiovascular morbidity and mortality.

Assuntos

Albuminúria/patologia , Proteína C-Reativa/metabolismo , Endotélio Vascular/patologia , Hipertensão/patologia , Hipertrofia Ventricular Esquerda/patologia , Inflamação/patologia , Idoso , Albuminúria/complicações , Albuminúria/fisiopatologia , Pressão Sanguínea/fisiologia , Estudos de Coortes , Estudos Transversais , Endotélio Vascular/fisiopatologia , Feminino , Humanos , Hipertensão/complicações , Hipertensão/metabolismo , Hipertensão/fisiopatologia , Hipertrofia Ventricular Esquerda/etiologia , Hipertrofia Ventricular Esquerda/metabolismo , Inflamação/complicações , Inflamação/metabolismo , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Fatores de Risco

RESUMO

A hipertensão arterial (HA) contribui para uma elevada mortalidade cardiovascular em todo o país. Conhecer a distribuição dos fatores de risco (FR) para HA em grupos populacionais é essencial para a redução desse importante problema de saúde pública. Esta revisão tem como objetivo apresentar as estimativas de prevalência dos FR para HA mais estudados: obesidade, diabetes, dislipidemia, sedentarismo, tabagismo e alcoolismo. A revisão incluiu artigos publicados em periódicos indexados nas bases Medline e Scielo nos últimos dez anos (1996-2005). Foram encontrados 117 artigos, dos quais 40 foram analisados. As prevalências gerais de obesidade variaram de 7,9 por cento a 20,8 por cento, com mediana de 12,7 por cento; o excesso de peso (EP) variou de 25,7 por cento a 51,6 por cento. A mediana das prevalências de colesterol total > 240 mg/dl foi 14,3 por cento. A prevalência geral de DM variou de 2,3 por cento a 36,2 por cento, com mediana de 6,1 por cento. Mais de dois terços dos indivíduos das populações estudadas não praticam atividades físicas regulares de forma adequada. A prevalência de abuso de álcool/alcoolismo variou de 2,9 por cento a 45,4 por cento. As prevalências encontradas de tabagismo ficaram em torno de 20 por cento a 30 por cento, mediana de 20,7 por cento. As prevalências dos FR ainda são elevadas, principalmente EP/obesidade e tabagismo. Esses dados mostram uma visão muito parcial da distribuição dos FR para HA no país, concentrando-se no eixo Rio-SP e RS, e apontam para a necessidade de estimular a realização de estudos populacionais nas regiões Norte, Centro-Oeste e Nordeste do país, além da importância do uso de definições padronizadas dos FR.

Assuntos

Humanos , Alcoolismo , Doenças Cardiovasculares , Diabetes Mellitus , Hiperlipidemias , Hipertensão/epidemiologia , Obesidade , Fatores de Risco , Tabagismo , Bases de Dados Bibliográficas

RESUMO

O artigo analisa indicadores de estrutura (docente-assistenciais e administrativos) e de processo presentes no Sistema de Informações dos Hospitais Universitários do Ministério da Educação (SIHUF/MEC), correlacionando-os com grau de complexidade (pontuação SIPAC/MEC) e perfil dos hospitais. Nas 45 unidades do país, há concentração de alta complexidade nos hospitais gerais, havendo associação positiva entre a complexidade e os seguintes indicadores de estrutura: porte, leitos de unidade de terapia intensiva (UTI), valor médio pago pela autorização de internação hospitalar (AHI), capacitação docente (todos com p<0,01), relação funcionário/leito e proporção de leitos de UTI (p=o,10 e p=0,09, respectivamente). Tanto o percentual do comprometimento da receita do Sistema Único de Saúde (SUS) com custeio e pessoal (p=0,10) quanto o preço negociado de oxigênio (p<0,01) foram mais altos em hospitais de menor complexidade. Também foi evidenciada correlação linear entre esses indicadores e o SIPAC/MEC: leitos hospitalares (R=0,76), capacitação docente: (R=0,70), leitos de UTI (R=0,65), relação AIH/internação (R=0,67) e preço de oxigênio (R=-0,55). Na regressão linear múltipla, a variação da complexidade foi explicada por: taxa de comprometimento da receita SUS, capacitação docente, preço de oxigênio e leitos totais (R²=0,75). O SIHUF/MEC pode ser explorado para definição de padrões de desempenho hospitalar e a variável SIPAC/MEC é medida válida para estratificar grupos de comparação.

Assuntos

Avaliação de Desempenho Profissional , Hospitais Universitários , Sistemas de Informação , Garantia da Qualidade dos Cuidados de Saúde , Indicadores de Qualidade em Assistência à Saúde

Assuntos

Humanos , Idoso , Doenças Cardiovasculares/epidemiologia , Medicina Baseada em Evidências , Medicina Preventiva , Fatores de Risco

Assuntos

Humanos , Adulto , Pessoa de Meia-Idade , Doenças Cardiovasculares/economia , Doenças Cardiovasculares/prevenção & controle , Promoção da Saúde , Saúde Pública , Qualidade de Vida , Sistemas de Saúde , Prevalência , Fatores de Risco

RESUMO

Os autores descrevem os primeiros casos de uveíte intermediária associada ao HTVL-I ( vírus linfotrópico para a célula-T ) no Brasil. Foram examinados 10 pacientes com HTVL-I ( Elisa e Western-Blot ) sendo encontradas alteraçöes como vasculite e exsudaçäo na retina periférica em três casos (33 por cento), um caso (10 por cento) com Síndrome de Spogren primária e outro (10 por cento), ainda näo descrito, de ceratite intersticial. O objetivo do estudo foi identificar alteraçöes oculares em pacientes soropositivos para HTVL-I, alertando para uma nova etiologia a ser pesquisada nas uveítes intermediárias contribuindo para diminuiçäo do número, ainda grande, de casos idiopáticos.

Assuntos

Humanos , Análise de Sequência de DNA/métodos , Vírus Linfotrópico T Tipo 1 Humano/patogenicidade , Infecções por HTLV-I/epidemiologia , Infecções por HTLV-I/etiologia , Infecções por HTLV-I/virologia , Ceratite/patologia , Síndrome de Sjogren/patologia , Uveíte/epidemiologia , Uveíte/história

RESUMO

Objetivo: Avaliar a importância do atendimento reumatológico em hospital universitário e estimar a prevalência das doenças reumatológicas nesse tipo de atendimento. Métodos: Levantamento dos totais de atendimentos ambulatoriais do hospital e do ambulatório de Reumatologia, no período de 1985 a 1991. Resultados: Cerca de 1/50 pacientes atendidos no Hospital apresenta doença reumatológica e 1/100 pacientes tem diagnóstico de doença inflamatória reumatológica, sendo as de maior freqüência as doenças degenerativas, posturais e de partes moles. No grupo inflamatório, a patologia mais encontrada é a artrite reumatóide e, como grupo de doenças, as espondiloartropatias. Conclusao: As doenças reumatológicas situam-se entre as de maior freqüência no atendimento ambulatorial de um hospital universitário, com preponderância da doenças degenerativas, posturais e de partes moles, as espondiloartropatias e a artrite reumatóide

Assuntos

Humanos , Assistência Ambulatorial , Epidemiologia , Hospitais Universitários , Ambulatório Hospitalar , Doenças Reumáticas , Sistemas de Saúde