Medical Students’ Awareness About Value-Based Health Care in Brazil: A Cross Sectional Study

Background: Rising healthcare costs demand a transition from the current fee-for-service to a Value-Based Health Care (VBHC) Model. This requires that all future doctors to understand the VBHC Model. We aimed to evaluate the VBHC awareness among Brazilian medical students and to identify it’s associated intrinsic/extrinsic factors through a survey-based, cross-sectional study. Methods: An online survey was sent to students from Brazilian medical schools. A descriptive analysis based on participants' level of awareness about VBHC was performed. The categorical variables included were absolute and relative frequencies using chi-square tests. A multivariate binary logistic regression analysis was performed by calculating the odds ratio (OR) and 95% confidence intervals (95%CI) to compare each response according to VBHC awareness. Results: We collected 3030 responses from 148 Medical Schools across all Brazilian states. Medical students were compared into 2 groups; 1 was familiar with VBHC (14%; 426); 2 were not (86%; 2575). The univariate analysis showed that group 1 was more willing to share clinical outcomes/costs data related to their practice (57.04%) compared to 2 (48.12%), p<0.01. The multivariate analysis showed that internship experience was the most relevant factor associated with VBHC exposure (OR 4.32 [CI 95% 1.82 - 10.24]). Conclusion: We found that few medical students understand VBHC concepts, and that exposure was due to self-education efforts. Our results suggest that medical schools have the potential to reinforce both intrinsic and extrinsic factors related to students with regards to VBHC knowledge in order to prepare future doctors to practice in a value-driven context

Reabilitação urbana e do edificado: Prémio APRUPP 2020

Este livro contém os contributos das dissertações de mestrado e tese de doutoramento premiadas no âmbito do Prémio APRUPP 2020. A divulgação do conhecimento é um imperativo das sociedades que promovem uma reabilitação integrada e sustentável, cuja preservação do Património faz parte da promoção da Cultura e da melhoria das condições de vida das populações. A edição de 2020 do Prémio APRUPP, de natureza pecuniária, foi dirigido especificamente para projetos de investigação que estivessem orientados para os seguintes tópicos gerais (de forma individual ou articulada): a) Intervenção mínima, máxima preservação do Património; b) Compatibilização entre o novo e o antigo (materiais e tecnologias não lesivas do Património); c) Durabilidade e sustentabilidade das técnicas de reabilitação. O Prémio APRUPP está orientado para o reconhecimento do mérito e contributo para a sociedade de trabalhos de investigação, de mestrado e de doutoramento, relevantes para o conhecimento de boas práticas de reabilitação urbana e proteção do património edificado, tanto a nível do conhecimento arquitetónico, patrimonial e urbano, como associado às ciências e tecnologias da construção. A Associação Portuguesa para a Reabilitação Urbana e Proteção do Património (APRUPP) tem por finalidade a promoção e divulgação dos conceitos de proteção e reabilitação urbana como principais estratégias para a salvaguarda da identidade e valorização do património construído, a redução das assimetrias sociais e a promoção da participação dos cidadãos. Para além de outros fins relacionados com a preservação do edificado de interesse histórico e patrimonial e a divulgação de práticas, saberes e conhecimentos no campo da reabilitação e da proteção do património, a APRUPP também assume como objetivo a divulgação de estudos e obras que investigam, aperfeiçoam e difundam boas práticas da reabilitação urbana e de edifícios. A Associação Portuguesa para a Reabilitação Urbana e Proteção do Património (APRUPP) acompanha, desde a sua fundação em 2012, a evolução dos processos de reabilitação de edifícios e reabilitação urbana no país. Durante este período verificou-se a saída da crise do setor da construção alicerçada no investimento imobiliário e no turismo. A APRUPP viu com grande expectativa a definição das Áreas de Reabilitação Urbana (ARU) e a sua implementação através das Operações de Reabilitação Urbana (ORU), que previam benefícios fiscais que poderiam ajudar também na melhoria do acesso à habitação. Contudo, a visão integrada que se perspetivava desde 2009, aquando da publicação do Regime jurídico da Reabilitação Urbana (Decreto-Lei nº 307/2009), veio a demonstrar grandes dificuldades estratégicas na conciliação com a proteção do Património e a sua preservação. Tal deveu-se em parte à falta de inventariação dos bens imóveis com interesse, à falta de medidas estratégicas nos instrumentos de gestão urbana dos municípios sobre a proteção e valorização do Património edificado não classificado, nomeadamente nos Planos DiretoresMunicipais, ARU e ORU, Planos de urbanização, etc. A esta lacuna veio-se juntar a falta de legislação e orientações estratégicas a nível nacional que incidissem sobre este Património, a perda de operários e técnicos especializados na área da reabilitação e de reduzida formação no currículo geral universitário que incidisse sobre o conhecimento dos materiais e sistemas construtivos antigos, os seus processos de degradação e de reparação. Por este motivo a entrada do Decreto-Lei nº 95/2019 de 18 de julho que estabeleceu o regime aplicável à reabilitação de edifícios ou frações autónomas, que veio trazer avanços importantes na procura de um equilíbrio maior nas intervenções de que o Património edificado poderia beneficiar, encontrou obstáculos na falta de formação técnica especializada que deveria sustentar a prova dos desvios à norma para garantir a preservação desse património. Em resultado deste conjunto de aspetos e da falta de definição adequada do termo “reabilitação” na legislação portuguesa, o recurso extensivo à demolição integral ou quase integral mantendo apenas a fachada tornou-se a prática corrente. Este retrocesso de décadas da forma de atuar no território não se apresenta apenas como uma perda de Património, mas também o crescimento exponencial de resíduos da construção e da falha de critérios de sustentabilidade nas decisões de intervenção integrada. Considerando que em 2021 o número de edifícios anteriores a 1919, os que representam a maior fatia da nossa arquitetura tradicional e antiga, baixou para 4,8% do conjunto edificado (INE, 2021), torna-se urgente reformular as modalidades de intervenção e a intervenção de estratégias verdadeiramente sustentáveis. Para que isto aconteça, é preciso que o conhecimento científico consolidado em casos reais seja divulgado pela comunidade técnica e que sejam definidas novas estratégias de intervenção no território.CACAO e OTISpublishe

Coronavírus: impacto das políticas públicas na prevenção contra a disseminação do SARS COV 2 no Brasil/ Coronavirus: impact of public policies in preventing the spread of SARS COV 2 in Brazil

O presente trabalho procura analisar a relação existente entre as políticas públicas preventivas utilizadas em municípios brasileiros e a diminuição da infecção e do contágio de brasileiros pelo SARS-COV-2. Diante da relevância do tema no panorama mundial, pretendeu-se investigar os modos de contágio, a maneira como a doença manifesta-se, quais são os sintomas mais característicos visando esclarecer e definir as medidas preventivas mais eficazes utilizadas para evitar a disseminação desse vírus que é o responsável pela pandemia que atinge a humanidade no ano de 2020. Diante disso, observa-se que a doença ainda não possui uma cura específica e assola praticamente todos os países do globo terrestre. Ao entender a gravidade dessa problemática, o Brasil foi escolhido como o centro do estudo a fim de que fosse feita a verificação de quais políticas públicas foram adotadas de modo abrangente a fim de frear a disseminação do vírus pelo território brasileiro. Verificando os números de mortos pelo coronavírus pôde-se, então averiguar as posturas adotadas pelos governantes estaduais que obtiveram êxito como forma preventiva a fim de apontar de que maneira essas ações governamentais puderam diminuir a circulação do vírus entre a população brasileira e postergar a chegada da segunda onda de contaminação no país.

Prevalence, predictors, and patient-reported outcomes of long COVID in hospitalized and non-hospitalized patients from the city of São Paulo, Brazil

BackgroundRobust data comparing long COVID in hospitalized and non-hospitalized patients in middle-income countries are limited.MethodsA retrospective cohort study was conducted in Brazil, including hospitalized and non-hospitalized patients. Long COVID was diagnosed at 90-day follow-up using WHO criteria. Demographic and clinical information, including the depression screening scale (PHQ-2) at day 30, was compared between the groups. If the PHQ-2 score is 3 or greater, major depressive disorder is likely. Logistic regression analysis identified predictors and protective factors for long COVID.ResultsA total of 291 hospitalized and 1,118 non-hospitalized patients with COVID-19 were included. The prevalence of long COVID was 47.1% and 49.5%, respectively. Multivariable logistic regression showed female sex (odds ratio [OR] = 4.50, 95% confidence interval (CI) 2.51–8.37), hypertension (OR = 2.90, 95% CI 1.52–5.69), PHQ-2 > 3 (OR = 6.50, 95% CI 1.68–33.4) and corticosteroid use during hospital stay (OR = 2.43, 95% CI 1.20–5.04) as predictors of long COVID in hospitalized patients, while female sex (OR = 2.52, 95% CI 1.95–3.27) and PHQ-2 > 3 (OR = 3.88, 95% CI 2.52–6.16) were predictors in non-hospitalized patients.ConclusionLong COVID was prevalent in both groups. Positive depression screening at day 30 post-infection can predict long COVID. Early screening of depression helps health staff to identify patients at a higher risk of long COVID, allowing an early diagnosis of the condition

Longer-term effectiveness of a heterologous coronavirus disease 2019 (COVID-19) vaccine booster in healthcare workers in Brazil

Abstract Objective: To compare the long-term vaccine effectiveness between those receiving viral vector [Oxford-AstraZeneca (ChAdOx1)] or inactivated viral (CoronaVac) primary series (2 doses) and those who received an mRNA booster (Pfizer/BioNTech) (the third dose) among healthcare workers (HCWs). Methods: We conducted a retrospective cohort study among HCWs (aged ≥18 years) in Brazil from January 2021 to July 2022. To assess the variation in the effectiveness of booster dose over time, we estimated the effectiveness rate by taking the log risk ratio as a function of time. Results: Of 14,532 HCWs, coronavirus disease 2019 (COVID-19) was confirmed in 56.3% of HCWs receiving 2 doses of CoronaVac vaccine versus 23.2% of HCWs receiving 2 doses of CoronaVac vaccine with mRNA booster (P < .001), and 37.1% of HCWs receiving 2 doses of ChAdOx1 vaccine versus 22.7% among HCWs receiving 2 doses of ChAdOx1 vaccine with mRNA booster (P < .001). The highest vaccine effectiveness with mRNA booster was observed 30 days after vaccination: 91% for the CoronaVac vaccine group and 97% for the ChAdOx1 vaccine group. Vacine effectiveness declined to 55% and 67%, respectively, at 180 days. Of 430 samples screened for mutations, 49.5% were SARS-CoV-2 delta variants and 34.2% were SARS-CoV-2 omicron variants. Conclusions: Heterologous COVID-19 vaccines were effective for up to 180 days in preventing COVID-19 in the SARS-CoV-2 delta and omicron variant eras, which suggests the need for a second booster

Awareness related to value-based health care among Brazilian Medical Students

Introduction: The steep global increase in healthcare costs demands a transition from the current fee-for-service to a Value-Based Health Care (VBHC) Model. According to Porter, value is defined as the outcomes that matter to patients over the costs for a full cycle of care. In order to build a solid basis for this change, it is imperative that the core concepts of VBHC are taught and discussed during and after medical school. The survey aimed at evaluating the degree of awareness related to VBHC among brazilian medical students and how that awareness would impact their professional future (primary objective). The secondary objective was to correlate intrinsic and extrinsic factors associated with the degree of awareness and exposure to VBHC. Methodology: This was a cross-sectional, prospective study, conducted through online surveys and applied to students from Brazilian medical schools who agreed to participate. Categorical variables were presented as integers and percentages. For univariate analysis, we performed chi-square tests with a 5% significance level. All analyses were performed using software R version 3.6.0. Results and Discussion: A total of 3,001 medical students from all Brazilian states completed the survey. Students were compared in 2 groups according to their awareness of VBHC, with 14% (426 respondents) declaring themselves familiar with VBHC concepts. An univariate analysis showed that medical students had contact with VBHC through classes, extracurricular activities, lectures and electronic sources. Students with a higher awareness of VBHC were more willing to share data on outcomes and costs related to their clinical practice for the benefit of cost reduction and quality improvement, if data were anonymous (57.04%) compared to those with no contact with VBHC (48.12%). Similarly, those with higher awareness of VBHC were more open to be evaluated and ranked by patients (32.86%), as long as data were anonymized, against 25.36% of those not familiar with the topic. VBHC enthusiasts were more inclined to pursue an MBA (19.95%), a career in management (11.74%) or research (17.14%) when compared to those with lower awareness (8.47%, 6.06% and 13.55%, respectively). Overall, students with higher awareness related to VBHC showed greater interest in areas beyond clinical practice, such as research, innovation, patient safety, quality, health economics, artificial intelligence and health policies. Conclusion: Awareness related to VBHC is still low among medical students. In a transforming Healthcare system this is an essential topic to be discussed in medical schools in order to prepare future professionals for the new scenario they will face when entering this new healthcare market. Although some students showed higher awareness related to VBHC, such awareness was mostly due to self-education efforts. It should be part of medical schools ́ responsibilities to provide education beyond clinical practice and research and include a deeper understanding of the healthcare system and strategies proposed to improve outcomes and costs and create value to patients, such as the proposed VBHC strategy

Cost-effectiveness of a second opinion program on spine surgeries: an economic analysis

Abstract Background In this study we proposed a new strategy to measure cost-effectiveness of second opinion program on spine surgery, using as measure of effectiveness the minimal important change (MIC) in the quality of life reported by patients, including the satisfaction questionnaire regarding the treatment and direct medical costs. Methods Retrospective analysis of patients with prior indication for spine surgery included in a second opinion program during May 2011 to May 2019. Treatment costs and outcomes were compared considering each patients’ recommended treatment before and after the second opinion. Costs were measured under the perspective of the hospital, including hospital stay, surgical room, physician and staff fees and other costs related to hospitalization when surgery was performed and physiotherapy or injection costs when a conservative treatment was recommended. Reoperation costs were also included. For comparison analysis, we used data based on our clinical practice, using data from patients who underwent the same type of surgical procedure as recommended by the first referral. The measure of effectiveness was the percentage of patients who achieved the MIC in quality of life measured by the EQ-5D-3 L 2 years after starting treatment. An incremental cost-effectiveness ratio (ICER) was calculated. Results Based upon the assessment of 1,088 patients that completed the entire second opinion process, conservative management was recommended for 662 (60.8%) patients; 49 (4.5%) were recommended to injection and 377 (34.7%) to surgery. Complex spine surgery, as arthrodesis, was recommended by second opinion in only 3.7% of cases. The program resulted in financial savings of -$6,705 per patient associated with appropriate treatment indication, with an incremental effectiveness of 0.077 patients achieving MIC when compared to the first referral, resulting in an ICER of$-87,066 per additional patient achieving the MIC, ranging between $-273,016 and$-41,832. Conclusion After 2 years of treatment, the second opinion program demonstrated the potential for cost-offsets associated with improved quality of life

Is it possible to estimate the number of patients with COVID-19 admitted to intensive care units and general wards using clinical and telemedicine data?

ABSTRACT Objective: To develop and validate predictive models to estimate the number of COVID-19 patients hospitalized in the intensive care units and general wards of a private not-for-profit hospital in São Paulo, Brazil. Methods: Two main models were developed. The first model calculated hospital occupation as the difference between predicted COVID-19 patient admissions, transfers between departments, and discharges, estimating admissions based on their weekly moving averages, segmented by general wards and intensive care units. Patient discharge predictions were based on a length of stay predictive model, assessing the clinical characteristics of patients hospitalized with COVID-19, including age group and usage of mechanical ventilation devices. The second model estimated hospital occupation based on the correlation with the number of telemedicine visits by patients diagnosed with COVID-19, utilizing correlational analysis to define the lag that maximized the correlation between the studied series. Both models were monitored for 365 days, from May 20th, 2021, to May 20th, 2022. Results: The first model predicted the number of hospitalized patients by department within an interval of up to 14 days. The second model estimated the total number of hospitalized patients for the following 8 days, considering calls attended by Hospital Israelita Albert Einstein’s telemedicine department. Considering the average daily predicted values for the intensive care unit and general ward across a forecast horizon of 8 days, as limited by the second model, the first and second models obtained R² values of 0.900 and 0.996, respectively and mean absolute errors of 8.885 and 2.524 beds, respectively. The performances of both models were monitored using the mean error, mean absolute error, and root mean squared error as a function of the forecast horizon in days. Conclusion: The model based on telemedicine use was the most accurate in the current analysis and was used to estimate COVID-19 hospital occupancy 8 days in advance, validating predictions of this nature in similar clinical contexts. The results encourage the expansion of this method to other pathologies, aiming to guarantee the standards of hospital care and conscious consumption of resources

Impact of a quality programme on overindication of surgeries for endometriosis and cholecystectomies

Approximately 45% of patients receive medical services with minimal or no benefit (low-value care). In addition to the increasing costs to the health system, performing invasive procedures without an indication poses a potentially preventable risk to patient safety. This study aimed to determine whether a managed quality improvement programme could prevent cholecystectomy and surgery for endometriosis treatment with minimal or no benefit to patients.This before-and-after study was conducted at a private hospital in São Paulo, Brazil, which has a main medical remuneration model of fee for service. All patients who underwent cholecystectomy or surgery for endometriosis between 1 August 2020 and 31 May 2021 were evaluated.The intervention consisted of allowing the performance of procedures that met previously defined criteria or for which the indications were validated by a board of experts.A total of 430 patients were included in this analysis. The programme prevented the unnecessary performance of 13% of cholecystectomies (p=0.0001) and 22.2% (p=0.0006) of surgeries for the treatment of endometriosis. This resulted in an estimated annual cost reduction to the health system of US$466 094.93.In a hospital with a private practice and fee-for-service medical remuneration, the definition of clear criteria for indicating surgery and the analysis of cases that did not meet these criteria by a board of reputable experts at the institution resulted in a statistically significant reduction in low-value cholecystectomies and endometriosis surgeries

Characterisation of microbial attack on archaeological bone

As part of an EU funded project to investigate the factors influencing bone preservation in the archaeological record, more than 250 bones from 41 archaeological sites in five countries spanning four climatic regions were studied for diagenetic alteration. Sites were selected to cover a range of environmental conditions and archaeological contexts. Microscopic and physical (mercury intrusion porosimetry) analyses of these bones revealed that the majority (68%) had suffered microbial attack. Furthermore, significant differences were found between animal and human bone in both the state of preservation and the type of microbial attack present. These differences in preservation might result from differences in early taphonomy of the bones. © 2003 Elsevier Science Ltd. All rights reserved