Exploring front liners’ knowledge, participation and evaluation in the implementation of a pay for performance program (PMAQ) in primary health care in Brazil

Purpose: This paper employs implementation theory and the political literature on performance measurement to understand how frontline health workers know, participate and evaluate the Brazilian National Program for Improving Access and Quality of Primary Care (PMAQ, 2nd round). Design/methodology/approach: This paper develops an implementation theory-driven qualitative analysis. The research is developed in the city of Goiania (Brazil): a challenging organizational context in primary care (PHC). Interviews were carried out with 25 frontliners – managers, doctors, nurses and community health workers. Data were thematically and hierarchically analysed according to theoretical concepts such as policy knowledge, policy adherence, forms of accountability, alternative logics, organizational capacity and policy feedback. Findings: Results show the need to foster organizational capacity, knowledge, participation and policy feedback at the frontline. Successful implementation would require those adaptations to counteract policy challenges/failures or the emergence of alternative logics. Research limitations/implications: The study was conducted in only one setting, however, our sample includes different types of professionals working in units with different levels of organization capacity, located in distinct HDs, expressing well the implementation of PMAQ/P4P. Qualitative researches need to be developed for further exploring the same/other factors. Social implications: Findings can be used to improve discussions/planning and design of P4P programs in the city and State of Goias. Originality/value: The majority of analysis of PMAQ are of a quantitative or results-based nature. This article focuses on politically significant and unanswered questions regarding the implementation of PMAQ

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): study protocol for a randomized controlled trial

BACKGROUND: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). METHODS/DESIGN: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH2O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure 6430 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. DISCUSSION: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration metho

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Implementation of the urban land regularization policy of social interest in Goiânia: process tracing of three case studies in the northwest region

Submitted by Ana Caroline Costa ([email protected]) on 2019-08-15T19:02:57Z No. of bitstreams: 2 Dissertação - Germano Araujo Coelho - 2019.pdf: 5237733 bytes, checksum: 0b3673f1357653592f81f07180b28065 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5)Approved for entry into archive by Luciana Ferreira ([email protected]) on 2019-08-16T11:49:04Z (GMT) No. of bitstreams: 2 Dissertação - Germano Araujo Coelho - 2019.pdf: 5237733 bytes, checksum: 0b3673f1357653592f81f07180b28065 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5)Made available in DSpace on 2019-08-16T11:49:04Z (GMT). No. of bitstreams: 2 Dissertação - Germano Araujo Coelho - 2019.pdf: 5237733 bytes, checksum: 0b3673f1357653592f81f07180b28065 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2019-07-04Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEGMost of the neighborhoods in the northwest region of the municipality of Goiânia are the result of housing policy promoted irregularly by the governments of the state of Goiás. During the long period, residents of these neighborhoods were unable to receive property titles. It was only from 2012 that the population began to receive the scriptures through the policy of land regularization of social interest implemented by the Housing Agency of the State of Goiás (Agehab). Thus, the objective of this research is to identify sufficient causal mechanisms to explain the results of the implementation of Agehab's land regularization policy, which began in 2008, in three case studies: São Domingos, Jardim Curitiba and the Casa Legal Program, which includes five neighborhoods (Floresta, Boa Vista, Vitória, São Carlos, Conjunto Primavera), condensed into a representative case of the general policy processes. It was used the process tracing method, of the explaining-outcome type, relying on ancillary evidence- gathering methods. Documentary analysis was performed, as well as in-depth interviews which were conducted with actors from the middle (07) and high-level (03) bureaucracies, as well as with community leaders from the studied neighborhoods (08), totaling 18 interviews. Hypotheses of causal mechanisms constructed based on Public Policy and urban policy literature were tested, and then non-systematic variables that emerged from the evidence in process tracing were added to the process tracing. As a result of the research, it is presented the combination of sufficient causal mechanisms of implementation to explain the products delivered by the policy (legal regularization and full regularization). The case of the São Domingos neighborhood was the starting point for the implementation of the policy, where occurred the process of policy learning within the Agency about the construction of the administrative and political process, as well as the beginning of rapprochement between Agehab and the region's population. The Casa Legal Program is marked by the effectiveness of the political and administrative process, in which the high and medium level bureaucracies played a large role in the results of politics, reaching the delivery of a large number of housing scriptures. Noteworthy in this case study is the tension process between politics and technique that resulted in the issuance of scriptures containing cadastral errors. The last case, from Jardim Curitiba, was the only one that received full regularization, which was only possible, due to the role of bureaucratic activism of the first Agency ́s management analyzed, which managed to articulate the transfer of PAC resources from the Ministry of Cities. During the implementation process, stands out the role of the Social Technical Work (TTS) in articulating with community leaders corrections in the initial urban intervention projects that had been elaborated by the technical bureaucracy without prior contact with the population of the neighborhood. It is also highlighted the role of ideas on land regularization, incorporated by Agehab's management and bureaucracies, in a way that impacted on how the Agency identified the housing problem, as well as the tools used to solve them.Grande parte dos bairros da Região Noroeste do Município de Goiânia é fruto de políticas habitacionais promovidas irregularmente por governos do Estado de Goiás. Durante longo período, os moradores desses bairros ficaram impossibilitados de receber os títulos das propriedades. Foi apenas, a partir de 2012, que a população começou a receber as escrituras por meio da política de regularização fundiária de interesse social implementada pela Agência Goiana de Habitação (Agehab). Assim, o objetivo deste trabalho é identificar os mecanismos causais suficientes para se explicar os resultados da implementação da política de regularização fundiária da Agehab, que se iniciou a partir do ano de 2008, em três casos: São Domingos, Jardim Curitiba e o Programa Casa Legal, que inclui cinco bairros (Floresta, Boa Vista, Vitória, São Carlos, Conjunto Primavera), condensados em um caso representativo dos processos gerais da política. O método utilizado é o process tracing do tipo explicação de resultado, contando com métodos auxiliares de coleta de evidência. Foram realizadas análise documental e entrevistas em profundidade com atores das burocracias de médio (07) e alto escalão (03), bem como com líderes comunitários dos bairros estudados (08), totalizando 18 entrevistas. Foram testadas hipóteses dos mecanismos causais construídos com base nas literaturas de Políticas Públicas e políticas urbanas e, em seguida, acrescentou-se variáveis não sistemáticas que emergiram nas evidências no process tracing. Como resultado da pesquisa, apresenta-se a combinação de mecanismos causais suficientes da implementação para se explicar os produtos entregues pela política (regularização jurídica e regularização plena). O caso do bairro São Domingos foi o ponto de partida para implementação da política, em que houve um aprendizado dentro da Agência acerca da construção do processo administrativo e político, bem como houve o início da reaproximação entre Agehab e população da região. O Casa Legal é marcado pela efetivação do processo político e administrativo, em que as burocracias de nível alto e médio tiveram grande papel nos resultados da política, alcançando a entrega de um grande número de escrituras. Destaca-se no caso, o processo de tensão entre política e técnica que teve como consequência a emissão de escrituras contendo erros cadastrais. O último caso, do Jardim Curitiba, foi o único que recebeu a regularização plena, o que só foi possível, devido ao papel do ativismo burocrático da primeira gestão da Agência analisada, que conseguiu articular a transferência de recursos do PAC junto ao Ministério das Cidades. Durante o processo de implementação, destaca-se o papel do Trabalho Técnico Social (TTS) em articular com lideranças comunitárias correções nos projetos iniciais de intervenção urbana que haviam sido elaborados pela burocracia média sem um contato prévio com a população do bairro. Ressalta-se também o papel das ideias sobre a regularização fundiária, incorporadas pela gestão e burocracias da Agehab, de forma que impactaram em como a Agência identificou o problema habitacional, bem como nos instrumentos utilizados para soluciona-los

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.13Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Effect of lung recruitment and titrated Positive End-Expiratory Pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome - A randomized clinical trial

IMPORTANCE: The effects of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remain uncertain. OBJECTIVE: To determine if lung recruitment associated with PEEP titration according to the best respiratory-system compliance decreases 28-day mortality of patients with moderate to severe ARDS compared with a conventional low-PEEP strategy. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized trial conducted at 120 intensive care units (ICUs) from 9 countries from November 17, 2011, through April 25, 2017, enrolling adults with moderate to severe ARDS. INTERVENTIONS: An experimental strategy with a lung recruitment maneuver and PEEP titration according to the best respiratory-system compliance (n = 501; experimental group) or a control strategy of low PEEP (n = 509). All patients received volume-assist control mode until weaning. MAIN OUTCOMES AND MEASURES: The primary outcome was all-cause mortality until 28 days. Secondary outcomes were length of ICU and hospital stay; ventilator-free days through day 28; pneumothorax requiring drainage within 7 days; barotrauma within 7 days; and ICU, in-hospital, and 6-month mortality. RESULTS: A total of 1010 patients (37.5% female; mean [SD] age, 50.9 [17.4] years) were enrolled and followed up. At 28 days, 277 of 501 patients (55.3%) in the experimental group and 251 of 509 patients (49.3%) in the control group had died (hazard ratio [HR], 1.20; 95% CI, 1.01 to 1.42; P = .041). Compared with the control group, the experimental group strategy increased 6-month mortality (65.3% vs 59.9%; HR, 1.18; 95% CI, 1.01 to 1.38; P = .04), decreased the number of mean ventilator-free days (5.3 vs 6.4; difference, −1.1; 95% CI, −2.1 to −0.1; P = .03), increased the risk of pneumothorax requiring drainage (3.2% vs 1.2%; difference, 2.0%; 95% CI, 0.0% to 4.0%; P = .03), and the risk of barotrauma (5.6% vs 1.6%; difference, 4.0%; 95% CI, 1.5% to 6.5%; P = .001). There were no significant differences in the length of ICU stay, length of hospital stay, ICU mortality, and in-hospital mortality. CONCLUSIONS AND RELEVANCE: In patients with moderate to severe ARDS, a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality. These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01374022

Paediatric COVID-19 mortality: a database analysis of the impact of health resource disparity

Background The impact of the COVID-19 pandemic on paediatric populations varied between high-income countries (HICs) versus low-income to middle-income countries (LMICs). We sought to investigate differences in paediatric clinical outcomes and identify factors contributing to disparity between countries.Methods The International Severe Acute Respiratory and Emerging Infections Consortium (ISARIC) COVID-19 database was queried to include children under 19 years of age admitted to hospital from January 2020 to April 2021 with suspected or confirmed COVID-19 diagnosis. Univariate and multivariable analysis of contributing factors for mortality were assessed by country group (HICs vs LMICs) as defined by the World Bank criteria.Results A total of 12 860 children (3819 from 21 HICs and 9041 from 15 LMICs) participated in this study. Of these, 8961 were laboratory-confirmed and 3899 suspected COVID-19 cases. About 52% of LMICs children were black, and more than 40% were infants and adolescent. Overall in-hospital mortality rate (95% CI) was 3.3% [=(3.0% to 3.6%), higher in LMICs than HICs (4.0% (3.6% to 4.4%) and 1.7% (1.3% to 2.1%), respectively). There were significant differences between country income groups in intervention profile, with higher use of antibiotics, antivirals, corticosteroids, prone positioning, high flow nasal cannula, non-invasive and invasive mechanical ventilation in HICs. Out of the 439 mechanically ventilated children, mortality occurred in 106 (24.1%) subjects, which was higher in LMICs than HICs (89 (43.6%) vs 17 (7.2%) respectively). Pre-existing infectious comorbidities (tuberculosis and HIV) and some complications (bacterial pneumonia, acute respiratory distress syndrome and myocarditis) were significantly higher in LMICs compared with HICs. On multivariable analysis, LMIC as country income group was associated with increased risk of mortality (adjusted HR 4.73 (3.16 to 7.10)).Conclusion Mortality and morbidities were higher in LMICs than HICs, and it may be attributable to differences in patient demographics, complications and access to supportive and treatment modalities

COVID-19 symptoms at hospital admission vary with age and sex: results from the ISARIC prospective multinational observational study

Background: The ISARIC prospective multinational observational study is the largest cohort of hospitalized patients with COVID-19. We present relationships of age, sex, and nationality to presenting symptoms. Methods: International, prospective observational study of 60 109 hospitalized symptomatic patients with laboratory-confirmed COVID-19 recruited from 43 countries between 30 January and 3 August 2020. Logistic regression was performed to evaluate relationships of age and sex to published COVID-19 case definitions and the most commonly reported symptoms. Results: ‘Typical’ symptoms of fever (69%), cough (68%) and shortness of breath (66%) were the most commonly reported. 92% of patients experienced at least one of these. Prevalence of typical symptoms was greatest in 30- to 60-year-olds (respectively 80, 79, 69%; at least one 95%). They were reported less frequently in children (≤ 18&nbsp;years: 69, 48, 23; 85%), older adults (≥ 70&nbsp;years: 61, 62, 65; 90%), and women (66, 66, 64; 90%; vs. men 71, 70, 67; 93%, each P &lt; 0.001). The most common atypical presentations under 60&nbsp;years of age were nausea and vomiting and abdominal pain, and over 60&nbsp;years was confusion. Regression models showed significant differences in symptoms with sex, age and country. Interpretation: This international collaboration has allowed us to report reliable symptom data from the largest cohort of patients admitted to hospital with COVID-19. Adults over 60 and children admitted to hospital with COVID-19 are less likely to present with typical symptoms. Nausea and vomiting are common atypical presentations under 30&nbsp;years. Confusion is a frequent atypical presentation of COVID-19 in adults over 60&nbsp;years. Women are less likely to experience typical symptoms than men