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BACKGROUND: Prescribing by pharmacists is an increasingly common practice worldwide. In Brazil regulation of this practice began in 2013, and the practice remains unexplored as a research topic. OBJECTIVE: We aimed to explore and gain insights into pharmacist prescribing practices in Brazil and assessing pharmacist's perceptions of their training and preparedness to prescribe medications. METHODS: A cross-sectional survey was conducted between October 2022 and March 2023 via convenience sampling. Data were collected using an online questionnaire covering sociodemographic issues, academic training, prescribing practices, and perceptions regarding the provision of pharmacist prescribing in ambulatory care. Exploratory descriptive analysis and Poisson regression were performed to estimate the associations between pharmacist characteristics and their practices in prescribing medicines. RESULTS: Among the 305 valid responses, 58.7% of the outpatient pharmacists stated that they had not prescribed any medication in the previous three years. Over-the-counter medication prescriptions were most common (42.0%). Only 4.6% of respondents had prescribed prescription-only medicines provided through collaborative agreement, with 2.6% reporting that they had adjusted doses, and 2.3% played a role in prescription renewal. Pharmacists living in Northeast regions tended to be more active prescribers (PR = 1.42; 95%CI 1.03-2.18), whereas those in primary healthcare (PR = 0.61; 95%CI 0.39-0.96) and self-declared Black pharmacists (PR = 0.30; 95%CI 0.10-0.97) prescribed less. Respondents strongly believed in the pharmacist's role as a prescriber, although they remained ambivalent regarding their responsibility for patient outcomes. Progress barriers include infrastructure gaps and strained relationships with physicians. CONCLUSIONS: This study suggests that pharmacists in Brazil predominantly prescribe over-the-counter medications, and variations in setting, region, and race can influence prescribing by pharmacist in ambulatory care.

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PURPOSE: The American College of Surgeons Standard 4.8 requires an institution to implement a survivorship program to become a Commission on Cancer (CoC)-accredited cancer center. The online information offered by these cancer centers can help educate patients and their caregivers about available services. We assessed the content of survivorship program websites of CoC-accredited cancer centers in the United States. METHODS: Of the 1245 CoC-accredited centers for adults, we sampled 325 institutions (26%) based proportionately on the 2019 new cancer cases by state. Website pages of the institutions' survivorship programs were assessed for information and services offered using the COC Standard 4.8. We included programs for adult survivors of adult- and childhood-onset cancers. RESULTS: 54.5% of the cancer centers did not have a survivorship program website. Of the 189 included programs, most were aimed at adult survivors in general, rather than those with specific cancer types. On average, five essential CoC-recommended services were described, most commonly nutrition, care plans, and psychology services. The least mentioned services were genetic counseling, fertility, and smoking cessation. Most programs described services offered to patients who had completed treatment, while 7.4% of described services for those with metastatic disease. CONCLUSION: More than half of CoC-accredited programs did have information about cancer survivorship programs on their websites and when included, had variable and limited description of services. IMPLICATIONS FOR CANCER SURVIVORS: Our study provides an overview of online cancer survivorship services and offers a methodology that may be used by cancer centers to review, expand, and improve the information described on their websites.

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As clínicas integradas em Odontologia constituem em um desafio para o ensino superior na formação do profissional, que deverá aprender a tratar as condições orofaciais de seu paciente de forma diferenciada no futuro próximo, aliando cada vez mais a Odontologia e as novas tecnologias. Objetivou-se com este estudo de revisão discutida entender o conceito de clínica integrada e suas perspectivas em consonância com as Diretrizes Curriculares Nacionais. Foi realizado um levantamento bibliográfico sistematizado nos bancos de dados eletrônicos: Lilacs, PubMed e Scielo. Os termos em português e inglês "Educação em Odontologia" (Dental Education), "Clínicas Odontológicas" (Dental Clinics), "Graduação" (Undergraduate Program), "Prestação Integrada de Cuidados de Saúde" (delivery of health care, integrated) e "Currículo" (Curriculum) foram utilizados como palavras-chave. Foram eleitos 23 artigos para esta revisão e extraídas as ideias principais dos textos tendo como base as metodologias utilizadas e os principais resultados. Os autores foram unânimes em ressaltar que as clínicas integradas em Odontologia exercem influência na formação e no preparo do egresso generalista através do treinamento sobre um planejamento global, inter e multidisciplinar como pilar essencial para um currículo integrativo e inovador.

ntegrated clinics in Dentistry present a challenge for higher education in the training of professionals, who must adapt their approach to treating orofacial conditions in the near future, increasingly incorporating Dentistry and new technologies. This review study aimed to comprehend the concept of integrated clinics and its alignment with the National Curricular Guidelines. A systematic bibliographic survey was conducted in the following electronic databases: Lilacs, PubMed, and Scielo. The search employed keywords in both Portuguese and English, including "Education in Dentistry" (Dental Education), "Dental Clinics", "Graduation" (undergraduate program), "Integrated Provision of Health Care" (delivery of health care, integrated), and "Curriculum." Approximately 23 articles were selected for this review, and the primary ideas within the texts were extracted based on the employed methodologies and the principal results. The authors unanimously emphasized that integrated dentistry clinics significantly impact the training and preparation of generalist graduates. This influence stems from emphasizing global, inter, and multidisciplinary planning as an indispensable foundation for an integrative and innovative curriculum.

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OBJECTIVE: There is no consensus for how to use rehabilitation visits after total knee arthroplasty (TKA). We sought to develop expert recommendations for outpatient rehabilitation visit usage after TKA. DESIGN: Delphi study. METHODS: First, we developed a broad list of preliminary visit usage recommendations, which were specific to patients' recovery status (ie, slow, typical, or fast recovery) and time since surgery. We then invited 49 TKA experts to participate on a Delphi panel. During round 1, we surveyed panelists regarding their level of agreement with each preliminary recommendation. We conducted additional Delphi rounds as needed to build consensus, which we defined using the RAND/UCLA method. We updated the survey each round based on panelist feedback and responses from the previous round. RESULTS: Thirty panelists agreed to participate, and 29 panelists completed 2 Delphi rounds. The panel reached consensus on recommendations related to visit frequency, visit timing, and the use of telerehabilitation. The panel recommended that outpatient rehabilitation should begin within 1 week after surgery at a frequency of 2 times per week for the first postoperative month regardless of recovery status. The panel recommended different visit frequencies depending on the patient's recovery status for postoperative months 2 to 3. The panel agreed that telerehabilitation can be recommended for most patients after TKA, but not for patients recovering slowly. CONCLUSION: We used the Delphi process to develop expert recommendations for the use of outpatient rehabilitation visits after TKA. We envision these recommendations could help patients decide how to use visits based on their own preferences. J Orthop Sports Phys Ther 2023;53(9):1-9. Epub: 10 July 2023. doi:10.2519/jospt.2023.11840.

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Objectives: To assess the accumulated knowledge of the effects of public health emergencies of international concern on disease control and local health systems, and contribute to a better understanding of their effects on health programs and systems. Methods: This was a systematic review of published and gray literature (in English, Portuguese, or Spanish). Electronic databases (BVS/LILACS, PubMed, and SciELO) and Google Scholar were searched. Search terms were: COVID-19 OR H1N1 OR Ebola OR Zika OR poliomyelitis AND (outbreaks OR epidemics) AND (public health systems OR public health surveillance). Results: A total of 3 508 studies were retrieved, of which 31 met the inclusion criteria. The studies addressed the effects of the emergencies on: communicable diseases notification systems; malaria, HIV/AIDS, tuberculosis, poliomyelitis, and malaria surveillance, control, and treatment; microcephaly; dengue; and vaccinations. The populations affected by the emergencies experienced reduced health services, which included fewer health visits, failures in the diagnostic chain, decrease in vaccination, and increased incidence or underreporting of notifiable diseases. Conclusions: Socioeconomic inequity is a determinant of the effects of public health emergencies of international concern within affected populations. The diversion of resources and attention from health authorities disproportionately affects vulnerable populations and can lead, over time, to a weakening of health systems. The analysis of the effects of public health emergencies is important for the development of new protocols that can better respond to future crises.

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ABSTRACT Objectives. To assess the accumulated knowledge of the effects of public health emergencies of international concern on disease control and local health systems, and contribute to a better understanding of their effects on health programs and systems. Methods. This was a systematic review of published and gray literature (in English, Portuguese, or Spanish). Electronic databases (BVS/LILACS, PubMed, and SciELO) and Google Scholar were searched. Search terms were: COVID-19 OR H1N1 OR Ebola OR Zika OR poliomyelitis AND (outbreaks OR epidemics) AND (public health systems OR public health surveillance). Results. A total of 3 508 studies were retrieved, of which 31 met the inclusion criteria. The studies addressed the effects of the emergencies on: communicable diseases notification systems; malaria, HIV/AIDS, tuberculosis, poliomyelitis, and malaria surveillance, control, and treatment; microcephaly; dengue; and vaccinations. The populations affected by the emergencies experienced reduced health services, which included fewer health visits, failures in the diagnostic chain, decrease in vaccination, and increased incidence or underreporting of notifiable diseases. Conclusions. Socioeconomic inequity is a determinant of the effects of public health emergencies of international concern within affected populations. The diversion of resources and attention from health authorities disproportionately affects vulnerable populations and can lead, over time, to a weakening of health systems. The analysis of the effects of public health emergencies is important for the development of new protocols that can better respond to future crises.

RESUMEN Objetivos. Evaluar el conocimiento acumulado acerca de los efectos de las emergencias de salud pública de importancia internacional en el control de enfermedades y en los sistemas de salud locales, y contribuir a una mejor comprensión de estos efectos en los programas y sistemas de salud. Métodos. Se hizo una revisión sistemática de bibliografía gris y publicada (en español, inglés o portugués) para la que se realizaron búsquedas en bases de datos electrónicas (BVS/LILACS, PubMed y SciELO) y en Google Scholar. Los términos de búsqueda fueron: COVID-19 OR H1N1 OR Ebola OR Zika OR poliomyelitis AND (Outbreaks OR epidemics) AND (public health systems OR public health surveillance). Resultados. Se encontraron 3 508 estudios, de los cuales 31 cumplieron los criterios de inclusión. En los estudios se abordaban los efectos de las emergencias en: los sistemas de notificación de enfermedades transmisibles; la vigilancia, el control y el tratamiento de la malaria, el VIH/sida, la tuberculosis y la poliomielitis; la microcefalia; el dengue; y las vacunas. Las poblaciones afectadas por las emergencias experimentaron una reducción de los servicios de salud, incluida una reducción de las consultas de salud, errores en la cadena de diagnóstico, una disminución de la vacunación y el aumento de la incidencia o subnotificación de enfermedades de notificación obligatoria. Conclusiones. La inequidad socioeconómica es un determinante de los efectos de las emergencias de salud pública de importancia internacional en los grupos poblacionales afectados. El desvío de recursos y atención de las autoridades de salud afecta desproporcionadamente a los grupos vulnerables y puede suponer, con el tiempo, un debilitamiento de los sistemas de salud. El análisis de los efectos de las emergencias de salud pública es crucial para la elaboración de nuevos protocolos que puedan mejorar la respuesta ante futuras crisis.

RESUMO Objetivos. Avaliar o conhecimento acumulado sobre os efeitos das emergências de saúde pública de importância internacional no controle de doenças e nos sistemas de saúde locais e contribuir para uma melhor compreensão desses efeitos sobre os programas e sistemas de saúde. Métodos. Trata-se de uma revisão sistemática da literatura branca e cinzenta (em inglês, português ou espanhol) realizada por meio de pesquisas nos bancos de dados eletrônicos BVS/LILACS, PubMed e SciELO e no Google Scholar. Foram utilizados os seguintes termos de busca: COVID-19 OR H1N1 OR Ebola OR Zika OR poliomyelitis AND (outbreaks OR epidemics) AND (public health systems OR public health surveillance). Resultados. Foi identificado um total de 3 508 estudos, dos quais 31 preencheram os critérios de inclusão. Os estudos abordavam os efeitos das emergências sobre: sistemas de notificação de doenças transmissíveis; vigilância, controle e tratamento de HIV/AIDS, tuberculose, poliomielite e malária; microcefalia; dengue; e vacinações. As populações afetadas pelas emergências enfrentaram uma redução nos serviços de saúde, como menos consultas médicas, problemas na cadeia de diagnóstico, diminuição da vacinação e maior incidência ou subnotificação de doenças de notificação compulsória. Conclusões. A desigualdade socioeconômica é um fator determinante dos efeitos das emergências de saúde pública de importância internacional nas populações afetadas. O desvio dos recursos e da atenção das autoridades sanitárias afeta desproporcionalmente as populações vulneráveis e pode levar, com o passar do tempo, a um enfraquecimento dos sistemas de saúde. A análise dos efeitos das emergências de saúde pública é importante para a elaboração de novos protocolos que possam enfrentar melhor futuras crises.

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Children in foster care have higher health care costs and poor care coordination, often due to inconsistent information exchanged between health care and child welfare systems. This study implemented secure automated information sharing and detected improvements in time spent gathering information, health care services delivered, and billing practices at participating health care systems.

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AIMS: The focus of health system interventions for noncommunicable diseases and diabetes focus mainly on primary health care responses. However, existing interventions are not necessarily adapted for the complex management of type 1 diabetes (T1DM). We aimed to identify and describe health system interventions which have been developed to improve the management of T1DM globally. METHODS: We conducted a scoping review by searching MEDLINE, Embase, and Global Health using OVID for peer-review articles published in either English, Spanish, Portuguese or French in the last 10 years. We classified the intervention strategies according to the Effective Practice and Organization of Care (EPOC) taxonomy for health system interventions and the World Health Organization (WHO) health system building blocks. RESULTS: This review identified 159 health system interventions to improve T1DM management. Over half of the studies focused only on children or adolescents with type 1 diabetes. Only a small fraction of the studies were conducted in low-and-middle income countries (LMICs). According to the EPOC taxonomy, the most frequently studied category was delivery arrangement interventions, while implementation strategies and financial arrangements were less frequently studied. Also, governance arrangements domains were not studied. The most common combination of intervention strategies included self-management with either telemedicine, use of information and smart home technologies. CONCLUSIONS: There is a need to expand potential interventions to other EPOC strategies to assess their potential effect on health outcomes in people with T1DM, as well as to involve more LMIC settings as the impact may be greater in these settings.

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INTRODUCTION: The number of cancer survivors is increasing in Colombia, and health policy changes are necessary to meet their unmet needs and improve their health outcomes. Similar trends have been identified in developed countries, and positive changes have been made. METHODS: We conducted a narrative review to provide an overview of Colombia's social structure, health care system, and health care delivery in relation to cancer, with recommendations for improving cancer survivorship in Colombia based on the model of survivorship care in the United States. RESULTS: We proposed general recommendations for improving cancer survivors' care including (1) recognizing cancer survivorship as a distinct phase of cancer, (2) strengthening methods and metrics for tracking cancer survivorship, (3) assessing and monitoring cancer symptoms and quality of life of cancer survivors, (4) publishing evidence-based guidelines considering the social, economic, and cultural characteristics of Colombian population and cancer survivors' specific needs. CONCLUSION: These recommendations could be used to inform and prioritize health policy development in Colombia related to cancer survivorship outcomes.

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Prolonged waiting to access health care is a primary concern for nations aiming for comprehensive effective care, due to its adverse effects on mortality, quality of life, and government approval. Here, we propose two novel bargaining frameworks to reduce waiting lists in two-tier health care systems with local and regional actors. In particular, we assess the impact of 1) trading patients on waiting lists among hospitals, the 2) introduction of the role of private hospitals in capturing unfulfilled demand, and the 3) hospitals' willingness to share capacity on the system performance. We calibrated our models with 2008-2018 Chilean waiting list data. If hospitals trade unattended patients, our game-theoretic models indicate a potential reduction of waiting lists of up to 37%. However, when private hospitals are introduced into the system, we found a possible reduction of waiting lists of up to 60%. Further analyses revealed a trade-off between diagnosing unserved demand and the additional expense of using private hospitals as a back-up system. In summary, our game-theoretic frameworks of waiting list management in two-tier health systems suggest that public-private cooperation can be an effective mechanism to reduce waiting lists. Further empirical and prospective evaluations are needed.

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ABSTRACT This article reimagines the health care system to focus on risk factors rather than outcomes in order to improve patient-centered care and reduce health care expenditure. Patient-centered care has been a global priority since 2001 when the Institute of Medicine declared it an essential aim for health care systems. As part of this discussion and to help facilitate this change, the concept of the big four risk factors - diet and nutrition; physical activity; smoking and tobacco use; and excessive alcohol consumption - is introduced in the context of the Americas from which it originates. Using peer-reviewed literature, health policy guidelines, theories, frameworks, and transdisciplinary implementation science strategies, this article explains how public health research and medical centers are set up in terms of disease, or outcome, rather than risk factor, or exposure. It suggests how moving from outcome-based health care models to focus on prevention using the big four risk factors will lead to better patient-centered care and health outcomes. Transdisciplinary research and complexity science, a framework largely developed and tested in Latin America, are recommended to facilitate this change and develop multicomponent, multistakeholder action and cooperation. Future research should pilot the proposed changes at various health-system levels and in different settings and report on the outcomes of implementation to assess effectiveness and improve translation of research, perhaps using the standardized RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) evaluation framework.

RESUMEN En este artículo se plantea un cambio en el sistema de atención de salud para que esté centrado no en los resultados sino en los factores de riesgo y así mejorar la atención centrada en el paciente y reducir el gasto en atención de salud. La atención centrada en el paciente ha sido una prioridad mundial desde el año 2001, cuando el Instituto de Medicina (IOM, por su sigla en inglés) la declaró un objetivo básico de los sistemas de atención de salud. En el marco de este debate y para ayudar a facilitar este cambio, se introduce el concepto de los cuatro grandes factores de riesgo (régimen alimentario y nutrición, actividad física, tabaquismo y consumo de tabaco, y consumo excesivo de alcohol) en el contexto de la Región de las Américas donde se origina. Empleando bibliografía publicada en revistas arbitradas, directrices de políticas de salud, teorías, marcos y estrategias científicas de aplicación transdisciplinaria, en este artículo se explica cómo se configuran la investigación de salud pública y los centros médicos en términos de enfermedad (o resultado) en lugar de factor de riesgo (o exposición). Se indica que al pasar de modelos de atención de salud basados en los resultados a modelos centrados en la prevención que usen los cuatro grandes factores de riesgo supondrá una mejora de la atención centrada en el paciente y de los resultados de salud. Se recomiendan la investigación transdisciplinaria y la ciencia de la complejidad, un marco creado y puesto a prueba en gran medida en América Latina, para facilitar este cambio y lograr medidas y cooperación con múltiples componentes y partes interesadas. La investigación que se haga en el futuro debería poner a prueba los cambios propuestos en varios niveles del sistema de salud y en diferentes entornos, y presentar información sobre los resultados de la implementación para evaluar la efectividad y mejorar la traducción de la investigación, tal vez utilizando el marco estandarizado de evaluación RE-AIM (sigla en inglés de cobertura, eficacia, adopción, implementación y mantenimiento).

RESUMO Este artigo reimagina o sistema de saúde para se concentrar nos fatores de risco e não nos desfechos, a fim de melhorar a atenção centrada no paciente e reduzir os gastos com a saúde. A atenção centrada no paciente tem sido uma prioridade global desde 2001, quando o Institute of Medicine dos EUA a declarou um objetivo essencial para os sistemas de saúde. Como parte dessa discussão e para ajudar a facilitar essa mudança, o conceito dos quatro grandes fatores de risco - dieta e nutrição, atividade física, tabagismo e uso de tabaco, e consumo excessivo de álcool - é introduzido no contexto das Américas, de onde ele se origina. Com base na literatura revisada por pares, diretrizes de políticas de saúde, teorias, estruturas e estratégias científicas de implementação transdisciplinar, este artigo explica como a pesquisa sobre saúde pública e os centros médicos são criados em função de doenças - ou desfechos -, em vez de fatores de risco - ou exposições. Sugere-se como a transição de modelos de saúde baseados em desfechos para um foco na prevenção, utilizando os quatro grandes fatores de risco, levará a uma melhor atenção centrada no paciente e a melhores desfechos de saúde. Recomenda-se o uso de pesquisa transdisciplinar e da ciência da complexidade - uma estrutura amplamente desenvolvida e testada na América Latina - para facilitar essa mudança e desenvolver ações e cooperação entre vários componentes e partes interessadas. Pesquisas futuras devem testar as mudanças propostas em vários níveis do sistema de saúde e em diferentes ambientes e informar sobre os resultados da implementação para avaliar a eficácia e melhorar a tradução da pesquisa, talvez utilizando a estrutura padronizada de avaliação RE-AIM (do inglês Reach, Effectiveness, Adoption, Implementation, Maintenance; em português, Alcance, Eficácia/Efetividade, Adoção, Implementação, Manutenção).

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Objetivo: identificar as evidências científicas sobre a assistência de enfermagem no atendimento pré-hospitalar a vítima de queimadura. Método: revisão de escopo realizada conforme orientações do Instituto Joanna Briggs e protocolo PRISMA-ScR. A busca foi executada em seis fontes de dados, no recorte temporal de 2016 a 2020. Doze artigos atenderam aos critérios de inclusão, sendo selecionados para a amostra dos resultados. Resultados: no âmbito da assistência de enfermagem, destacaramse reposição volêmica com infusão de fluidos; resfriamento local com água limpa, corrente e em temperatura ambiente; monitoramento/controle dos sinais vitais, uso de oxigenoterapia; analgesia e cuidados com a ferida, utilizando coberturas oclusivas, identificação do agente causador, avaliação da Superfície Corporal Queimada, extensão e profundidade da lesão. Conclusão: a assistência de enfermagem frente ao atendimento pré-hospitalar às vítimas de queimaduras se dá principalmente pelo controle da evolução dos danos causados pelo incidente desde o momento da chegada até o atendimento terciário.

Objective: to identify the scientific evidence on nursing in pre-hospital care for burn victims. Method: this scoping Review was conducted following the Joanna Briggs Institute guidelines and the PRISMA-ScR protocol. Six data sources were searched in the time frame from 2016 to 2020. Twelve articles met the inclusion criteria and were selected for sampling of the results. Results: prominent within the scope of nursing care were fluid volume replacement by infusion; local cooling with clean, running water at room temperature; monitoring / control of vital signs, use of oxygen therapy; analgesia and wound care, using occlusive dressings, identification of the causative agent, assessment of the Burned Body Surface Area, extent and depth of the injury. Conclusion: nursing in pre-hospital care for burn victims mainly involves controlling the progression of the injury caused by the incident between the moment of arrival and tertiary care.

Objetivo: identificar la evidencia científica sobre la asistencia de enfermería en la atención prehospitalaria a víctimas de quemaduras. Método: Revisión del alcance realizada según las orientaciones del Instituto Joanna Briggs y el protocolo PRISMAScR. La investigación se realizó sobre seis fuentes de datos, en el período de 2016 a 2020. Doce artículos cumplieron los criterios de inclusión y fueron seleccionados para la muestra de los resultados. Resultados: en el ámbito de la atención de enfermería se destacó la reposición volémica a través infusión de fluidos; enfriamiento local con agua corriente limpia en temperatura ambiente; seguimiento / control de signos vitales, uso de oxigenoterapia; analgesia y cuidado de heridas, utilizando curas oclusivas, identificación del agente causante, evaluación de la superficie corporal quemada, extensión y profundidad de la lesión. Conclusión: la asistencia de la enfermería ante la atención prehospitalaria a las víctimas de quemaduras ocurre principalmente mediante el control de la evolución de los daños ocasionados por el incidente desde el momento de la llegada hasta la atención terciaria.

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Resumo O artigo analisa a configuração das relações público-privadas no sistema de saúde do Chile, no período de 2000 a 2018. As dimensões de análise abordaram a organização e a regulação, o financiamento e a prestação de serviços de saúde. Foram utilizadas como técnicas de pesquisa: revisão bibliográfica, análise de documentos e de dados secundários e entrevistas. Três principais achados foram observados. Na dimensão organizacional e regulatória observou-se escassez de mecanismos institucionais que atenuem a seleção de riscos e vinculação do acesso à capacidade de contribuição dos afiliados do subsistema privado. O modelo de financiamento adotado foi insuficiente para a manutenção do sistema público. Em relação à prestação, apesar da implementação de estratégias que sugerem avanços, a fragmentação do sistema e a compra de serviços privados mantêm a segmentação do sistema. No sistema de saúde chileno, o caráter das relações público-privadas nas dimensões analisadas reitera a segmentação entre grupos populacionais produzidos pela lógica de priorização dos mercados na saúde. As reformas implementadas no período de análise atenuaram os efeitos da segmentação, mas não foram capazes de produzir mudanças estruturais na configuração do sistema de saúde.

Abstract This article analyzes the configuration of public-private relations in Chile's health system between 2000 and 2018, focusing on organization and regulation, funding and service delivery. The following data collection methods were employed: literature review, content analysis of official documents and secondary data, and semi-structured interviews. With regard to organization and regulation, the findings show a lack of institutional mechanisms to mitigate risk selection and that access to private services is intimately linked to ability to pay. The funding model is incapable of sustaining the public health system. With respect to service delivery, despite the implementation of strategies that suggest advances, the segmentation of the system is sustained by the fragmentation of care and purchase of private services. Our findings show that the nature of public-private relations in Chile's health system reinforces the segmentation of population groups produced by the market-oriented approach. Although the reforms implemented during the study period mitigate the effects of segmentation, they were unable to produce structural changes in the configuration of the health system.

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Developing robust systems for cancer care delivery is essential to reduce the high cancer mortality in small island developing states (SIDS). Indigenous data are scarce, but community-based cancer research can inform care in SIDS where formal research capacity is lacking, and we describe the experiences of cancer survivors in Saint Lucia in accessing health services. Purposive and snowball sampling was used to constitute a sample of survivors for interviews. Subjects were interviewed with a questionnaire regarding socio-demographics, clinical characteristics, health services accessed (physicians, tests, treatment), and personal appraisal of experience. We recruited 50 survivors (13 men, 37 women). Only 52% of first presentations were with general practitioners. The mean turnaround for biopsy results in Saint Lucia was three times longer than overseas (p = 0.0013). Approximately half of survivors commenced treatment more than one month following diagnosis (median of 32 days, IQR 19-86 days), and 56% of survivors traveled out-of-country for treatment. Most survivors (60%) paid for care with family/friends support, followed by savings and medical insurance (38% each). In conclusion, cancer survivors in Saint Lucia are faced with complex circumstances, including access-to-care and health consequences. This study can guide future research, and possibly guide practice improvements in the near term.

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BACKGROUND: Between 2006 and 2013, Peru implemented national programs which drastically decreased rates of maternal and neonatal mortality. However, since 2013, maternal and neonatal mortality in Peru have increased. Additionally, discrimination, abuse, and violence against women persists globally and impacts birthing experiences and mental health. This qualitative study sought to better understand the attitudes and beliefs regarding childbirth among women and providers in Southern Peru. This study also explores how these beliefs influence utilization of skilled care, patient-provider dynamics, and childbirth experiences and identifies factors that impact providers' provision of care. METHODS: Thirty semi-structured interviews were conducted with 15 participants from rural Colca Canyon and 15 participants from urban Arequipa between April and May 2018. In each region, 10 women who had experienced recent births and five providers were interviewed. Provider participants predominantly identified as female and were mostly midwives. All interviews were conducted, transcribed, and coded in Spanish. A framework analysis was followed, and data were charted into two separate thematic frameworks using contextual and evaluative categories of conceptualization of childbirth. RESULTS: All recent births discussed were facility-based births. Four domains emerged: women's current birth experiences, provision of childbirth care, beliefs about childbirth among women and providers, and future health-seeking behavior. Findings suggest that women's feelings of helplessness and frustration were exacerbated by their unmet desire for respectful maternity care and patient advocacy or companionship. Providers attributed strain to perceived patient characteristics and insufficient support, including resources and staff. CONCLUSIONS: Our findings suggest current childbirth experiences placed strain on the patient-provider dynamic and influenced women's attitudes and beliefs about future experiences. Currently, the technical quality of safe childbirth is the main driver of skilled birth attendance and facility-based births for women regardless of negative experiences. However, lack of respectful maternity care has been shown to have major long-term implications for women and subsequently, their children. This is one of the first studies to describe the nuances of patient-provider relationships and women's childbirth experiences in rural and urban Peru.

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Resumo Este artigo busca analisar o acesso e a continuidade do cuidado em trajetórias assistenciais de mulheres através da identificação dos principais pontos de apoio na rede de atenção à saúde. Trata-se de uma pesquisa qualitativa, realizada em uma região de saúde do Rio de Janeiro, a partir de entrevista semiestruturada com 21 mulheres para produção de suas trajetórias assistenciais. Os dados foram tratados por meio de análise de conteúdo e categorizados em quatro unidades temáticas: os agentes comunitários de saúde, identificados como o primeiro contato e facilitadores do acesso à rede; os profissionais de enfermagem, com quem se estabeleceram os mais fortes vínculos longitudinais e alguma possibilidade de continuidade do cuidado; o médico, que representava a expectativa de cura, mas onde os laços e a comunicação com as usuárias foram mais frágeis; e outros pontos de apoio, representados por atores intermediários (amigos, familiares, figuras políticas e outros) presentes ora como apoio, ora como facilitadores do acesso ao cuidado oportuno. O mosaico de trajetórias produzidas pelas mulheres na rede de atenção à saúde indicou fragilidades para garantia de acesso e continuidade do cuidado, mas também potências para a produção de intervenções e práticas que respondam a desejos e necessidades em saúde.

Abstract This article seeks to analyze the access and continuity of care in women's care trajectories through the identification of the main points of support in the health care network. This is a qualitative research, carried out in a health region of Rio de Janeiro, based on a semi-structured interview with 21 women to produce their care trajectories. The data were treated through content analysis and categorized into four thematic units: community health agents, identified as the first contact and facilitators of access to the network; nursing professionals, with whom the strongest longitudinal bonds and some possibility of continuity of care were established; the doctor, who represented the expectation of a cure, but where ties and communication with users were more fragile; and other points of support, represented by intermediate actors (friends, family, political figures and others) present at times as support, at times as facilitators of access to timely care. The mosaic of trajectories produced by women in the health care network indicated weaknesses to guarantee access and continuity of care, but also potencies to produce interventions and practices that respond to health wants and needs.

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O presente trabalho objetiva compreender a configuração da rede de cuidado em saúde mental da infância e adolescência em Quixadá, Ceará, partindo dos pacientes atendidos na clínica-escola de psicologia do Centro Universitário Católica de Quixadá. Trata-se de uma pesquisa documental e de natureza quantitativo-exploratória. Os dados foram analisados a partir do modelo estatístico descritivo. A clientela é, predominantemente, de meninos, de 4 a 12 anos, residentes no município de Quixadá e que não estão e nem estiveram em outros serviços de saúde, educação ou assistência social para tratar da queixa apresentada. Diante disso, acreditamos que a clínica-escola tem um grande valor social, dando o suporte aos equipamentos da rede, uma vez que a rede formal de cuidados não possui uma instituição de referência nesse tipo de atendimento.

This research aims to understand the configuration of the mental health care network of children and adolescents in Quixadá, Ceará, starting from the patients attended at the psychology school clinic of the Centro Universitário Católica de Quixadá. It is a documentary and quantitative-exploratory research. The clientele are predominantly boys, aged 4 to 12 years, resident in Quixadá city, and who are not and have not been to other health, education, or social assistance services, to deal with the complaint. Given this, we believe that the school clinic has a great social value, supporting the equipment of the network since the formal care network does not have a reference institution in this type of care.

Esta investigación tiene como objetivo comprender la configuración de la red de atención de salud mental de niños y adolescentes en Quixadá, Ceará, a partir de los pacientes atendidos en la clínica-escuela de Psicología del Centro Universitário Católica de Quixadá. Es una investigación documental y cuantitativa-exploratoria. La clientela es predominantemente de niños, de 4 a 12 años, residentes en la ciudad de Quixadá y que no están y no han estado en otros servicios de salud, educación o asistencia social para tratar de la queja presentada. Ante eso, creemos que la clínica escolar tiene un gran valor social, ofreciendo respaldo al equipo de la red, ya que la red de atención formal no tiene una institución de referencia en este tipo de atención.

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INTRODUCTION: During the COVID-19 pandemic, excess mortality has been reported, while hospitalisations for acute cardiovascular events reduced. Brazil is the second country with more deaths due to COVID-19. We aimed to evaluate excess cardiovascular mortality during COVID-19 pandemic in 6 Brazilian capital cities. METHODS: Using the Civil Registry public database, we evaluated total and cardiovascular excess deaths, further stratified in specified cardiovascular deaths (acute coronary syndromes and stroke) and unspecified cardiovascular deaths in the 6 Brazilian cities with greater number of COVID-19 deaths (São Paulo, Rio de Janeiro, Fortaleza, Recife, Belém, Manaus). We compared observed with expected deaths from epidemiological weeks 12-22 of 2020. We also compared the number of hospital and home deaths during the period. RESULTS: There were 65 449 deaths and 17 877 COVID-19 deaths in the studied period and cities for 2020. Cardiovascular mortality increased in most cities, with greater magnitude in the Northern capitals. However, while there was a reduction in specified cardiovascular deaths in the most cities, the Northern capitals showed an increase of these events. For unspecified cardiovascular deaths, there was a marked increase in all cities, which strongly correlated to the rise in home deaths (r=0.86, p=0.01). CONCLUSION: Excess cardiovascular mortality was greater in the less developed cities, possibly associated with healthcare collapse. Specified cardiovascular deaths decreased in the most developed cities, in parallel with an increase in unspecified cardiovascular and home deaths, presumably as a result of misdiagnosis. Conversely, specified cardiovascular deaths increased in cities with a healthcare collapse.

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Introdução: A análise das referências médicas de pacientes da Atenção Primária à Saúde (APS) para especialidades focais traz questões relevantes para a formulação e administração de políticas do sistema de saúde. A detecção de encaminhamentos potencialmente evitáveis pode permitir um aprimoramento dos processos de trabalho, assim como otimizar a alocação de recursos. Objetivo: Descrever as referências secundárias geradas por médicos de uma Unidade de APS vinculada ao Grupo Hospitalar Conceição (GHC), no ano de 2017, e construir critérios para classificá-las, discutindo sua evitabilidade. Métodos: Estudo descritivo-exploratório, baseado em documentação. Os dados foram obtidos no sistema GERCON® (Sistema de Gerenciamento de Consultas da Secretaria Municipal de Saúde de Porto Alegre/RS). Os encaminhamentos foram classificados conforme seu motivo e também conforme sua evitabilidade. Resultados: Foram gerados 799 encaminhamentos, a 110 especialidades médicas no período. Após a exclusão das especialidades de dermatologia e de pré-natal de alto risco (por mudança nos critérios e fluxos de encaminhamento, durante 2017), restaram 733 referenciamentos. Destes, 582 foram categorizados pelas pesquisadoras como não evitáveis e 151 como evitáveis. Os motivos de encaminhamentos predominantes foram: terapêuticas não disponíveis na APS (34%), recursos diagnósticos não disponíveis em APS (26,5%) e dúvida diagnóstica ou terapêutica (23,2%). Em relação à evitabilidade, foram identificados 20,6% de referenciamentos evitáveis, predominando aqueles que envolviam carência de conhecimentos/habilidades/ atitude do médico. Quanto aos encaminhamentos categorizados como não evitáveis (79,4%), predominaram aqueles efetivados por necessidade de conhecimentos/habilidades/procedimentos não próprios à APS. Conclusão: A construção de um conceito para referências evitáveis, a partir de estudos empíricos, pode enriquecer a gestão de serviços de APS, tendo em vista sua resolutividade. O presente estudo encontrou, nessa Unidade de APS, um baixo percentual de encaminhamentos potencialmente evitáveis.

Introduction: The analysis of medical referrals from Primary Health Care (PHC) patients to focal specialties brings relevant issues to the formulation and administration of health system policies. The detection of potentially avoidable routing can allow an improvement in work processes, as well as optimize resource allocation. Objective: To describe the secondary references generated by physicians from a PHC unit linked to the Grupo Hospitalar Conceição (GHC), in 2017, and to build criteria to classify them, discussing their avoidability. Methods: A descriptive exploratory study based on documentation. The data were obtained from the GERCON® system (Query Management System of the Municipal Health Department of Porto Alegre/RS). The referrals were classified according to their motive and according to their avoidability. Results: 799 referrals were generated, to 110 medical specialties in the period. After excluding of high-risk prenatal and dermatology specialties (due to changes in criteria and referral flows during 2017), 733 referrals remained. Of these, 582 were categorized by the researchers as non-preventable and 151 as avoidable. The predominant reasons for referral were: therapies not available in PHC (34%), diagnostic resources not available in PHC (26.5%), and diagnostic or therapeutic doubt (23.2%). 20.6% of preventable referrals were identified with a predominance of those involving lack of physician knowledge/skills/attitude, regarding avoidability. Regarding referrals categorized as non-avoidable (79.4%), those carried out due to the need for knowledge/skills/procedures not proper to PHC predominated. Conclusion: The construction of a concept for avoidable references from empirical studies can enrich the management of PHC services, in view of their resolution. The present study found, in this PHC Unit, a low percentage of potentially preventable referrals.

Introducción: El análisis de las referencias médicas de los pacientes de la Atención Primaria a la Salud (APS) a las especialidades focales aporta questiones pertinentes para la formulación y administración de políticas del sistema de salud. La detección de encaminamientos potencialmente evitables puede permitir mejorar los procesos de trabajo, así como optimizar la asignación de recursos. Objetivo: Describir las referencias secundarias generadas por los médicos de una Unidad de APS vinculada al Grupo Hospitalar Conceição (GHC), en el año 2017, y construir criterios para clasificarlas, discutiendo su evitabilidad. Métodos: Estudio descriptivo exploratorio basado en documentación. Los datos se obtuvieron en el sistema GERCON® (Sistema de Gestión de Consultas de la Secretaría Municipal de Salud de Porto Alegre-RS). Los encaminamientos se clasificaron según su motivo y evitabilidad. Resultados: Se generaron 799 encaminamientos a 110 especialidades médicas en el período. Después de la exclusión de las especialidades de dermatología y de prenatal de alto riesgo (debido a los cambios en los criterios y flujos de encaminamiento durante 2017), quedaron 733 referencias. De estos, 582 fueron categorizados por las investigadoras como no evitables y 151 como evitables. Los motivos predominantes de encaminamientos fueron: terapéuticas no disponibles en la APS (34%), recursos diagnósticos no disponibles en la APS (26,5%) y duda diagnóstica o terapéutica (23,2%). En cuanto a la evitación, se identificó el 20,6% de referencias evitables, predominando aquellos que involucran carencia de conocimientos/habilidades/actitud del médico. En cuanto a los encaminamientos categorizados como no evitables (79,4%), predominaron aquellos realizados a la necesidad de conocimientos/habilidades/procedimientos no propios de la APS. Conclusión: La construcción de un concepto para Referencias Evitables a partir de estudios empíricos puede enriquecer la gestión de servicios de APS, teniendo en vista su resolutividad. El presente estudio encontró un bajo porcentual de encaminamientos potencialmente evitables en esta Unidad de APS.

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Introdução: Novas formas de integração dos serviços de saúde têm sido propostas, com base no fortalecimento da Atenção Primária à Saúde (APS), principalmente, por meio de seu atributo de coordenação, colocando-a como um eixo estruturante dos Sistemas Universais de Saúde. Uma das propostas de integração constitui-se na implementação de Redes de Atenção à Saúde, conceituadas como os serviços e ações que intervêm em processos de saúde-doença em diferentes densidades tecnológicas, logísticas e de gestão. Objetivo: Avaliar a capacidade da Atenção Primária à Saúde para coordenar as Redes de Atenção à Saúde. Métodos: Tratou-se de um estudo do tipo transversal analítico, que foi realizado nas Unidades de Saúde da Atenção Primária do município de Porto Alegre, Rio Grande do Sul, Brasil. Foram selecionadas 41 Unidades de Saúde por meio de amostragem aleatória sistemática. A amostra do estudo foi composta por 371 trabalhadores de saúde, selecionados por meio de amostragem por cotas. Para a coleta dos dados foi aplicado o Instrumento de Avaliação da Coordenação das Redes de Atenção à Saúde pela Atenção Primária (COPAS), no período de novembro de 2018 a maio de 2019. Resultados: A idade mediana foi de 39 anos, com um intervalo interquartílico de 32 a 48 anos. O tempo mediano de serviço na APS foi de 6 anos, com intervalo interquartílico de 4 a 10 anos. A fidedignidade do instrumento, avaliada por meio do coeficiente Alfa de Cronbach, demonstrou que todas as dimensões tiveram coeficientes acima de 0,70. Quando comparadas as dimensões do COPAS com os modelos de atenção à saúde (Estratégia de Saúde da Família e Unidade Básica de Saúde Tradicional) não houve diferença significativa entre os escores (p<0,005). Constatou-se o menor escore da dimensão "Sistemas Logísticos" (registro eletrônico, sistemas de acesso e regulação e os sistemas de transporte) em relação às demais dimensões do instrumento. A dimensão "Sistemas de Apoio" (serviços de apoio diagnóstico e terapêutico, sistemas de informação e sistemas de teleassistência) obteve o menor escore na comparação com as Gerências Distritais. O escore global da avaliação da capacidade da APS em coordenar redes de atenção atingiu 60,01%. Conclusões: A análise da capacidade da APS em coordenar as RAS mostra-se relevante no escopo da avaliação em saúde e na implementação do cuidado integrado. Além disso, reafirma o papel central da APS como porta de entrada do sistema de saúde, ordenadora de fluxos dos sistemas de saúde. O estágio de desenvolvimento da APS, classificada como "Condição boa, requer a implementação e utilização de tecnologias da informação, protocolos para regulação dos serviços e garantia de acesso aos serviços de saúde. Essas ações revelam-se necessárias para melhoria do cuidado sequencial e complementar entre os níveis de atenção.

Introduction: Based on reinforcement of Primary Health Care (PHC) it has been proposed recent ways of integrating the health services mainly focusing on the coordination attribute and thus considering it as a structuring axis of the Universal Health Care Systems. As example of integration proposals, the stablishing of Health Care Systems is taken as part of it and also taken into account as services and actions which operate on health-disease processes in different technological, logistical and management densities. Objective: To Assess the Primary Health Care capacity in order to coordinate Health Care Systems. Methods: This is an analytical cross-sectional study, carried out in Primary Care Health Units in the city of Porto Alegre, Rio Grande do Sul, Brazil. Therefore, 41 Health Units were selected through systematic random sampling composed of 371 health workers, selected through quota sampling. The Assessment of the Coordination of Integrated Health Service Delivery Networks by Primary Health Care Instrument (COPAS) was applied as data collecting tool, from November 2018 to May 2019. Results: The median age was 39 years, with an interquartile range of 32 to 48 years. The median length of service in PHC was 6 years, with an interquartile range of 4 to 10 years. The instrument's reliability, assessed by means of the Cronbach's Alpha coefficient, demonstrated that all dimensions had coefficients above 0.70. When the dimensions of COPAS were compared with the models of health care systems as Family Health Strategy and Basic Unit of Traditional Health, no significant difference between the scores (p <0.005) were evidenced. The lowest score of the dimension "Logistic Systems" (electronic record, access and regulation systems and transport systems) was found in relation to the other dimensions of the instrument. The "Support Systems" dimension (diagnostic and therapeutic support services, information systems and tele-assistance systems) presented the lowest score upon being compared with the District Managements. The assessment global score regarding Heath Care Systems reached 60.01%. Conclusion: The analysis of the PHC's ability to coordinate the Health Care Network is relevant in the scope of health assessment and in the implementation of integrated care. In addition, it reaffirms the central role of PHC as a gateway to the health system, organizing health system flows. The PHC development stage, classified as "In a good condition, requires the implementation and use of information technologies, protocols for regulating services and ensuring access to health services. These actions are necessary to improve sequential and complementary care between levels of care.

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