Assessment of a framework for the allocation of primary dental services

Philosophiae Doctor - PhDBackground: Standardized and evidence-based resource allocation frameworks for timely provision of primary dental services may support equitable distribution of comprehensive dental care. However, such frameworks, which can be applicable to primary care settings in Brazil, are not available. The purpose of this study was to explore the complex issue of equity allocation of dental staff for primary dental care services, by estimating time to dental disease progression in order to analyze costs when survival targets are set for patients waiting for primary dental care. The inclusion of wait time benchmarks for dental services in the design of the framework was an attempt to increase knowledge on the quality of access experienced by people living within catchment areas of the Family Health Strategy in Brazil. In view of ever scarce resources for public health services, ethical dilemmas arise in resource allocation when allocation choices require priority setting among individuals who face similar health needs. Since equity of access must be assured for all Brazilian citizens, the present study proposed a rational resource allocation model to help decision-makers in reconciling equity access and budgets. Aim: This study aimed to compare equity of access to dental services and costs of dental staff of two models for primary care settings. Additionally, staffing requirements and staff costs were projected over a three-year time period. Both models comprised three inter-related components: (i) universal access to oral health care, (ii) comprehensiveness of primary dental care and (iii) equity of access to primary dental services. Method: The present study was part empirical and part modeling in design. In the empirical phase, a set of maximum wait times for dental care determined by experts (Model 1) vs. wait times derived from survival analysis (Model 2) was compared. A one-year follow-up of a cohort of dental patients assigned to five primary health care clinics was conducted. The event of interest was clinical deterioration in the waiting time for dental visits. At each consultation with a dentist either for routine or emergency reasons, the oral quadrants of the patient were assessed and classified according to their urgency for dental care (from 1, less urgent to 5, more urgent). In the modeling phase, costs of dental staff were estimated on the basis of survival probabilities found in Model 1 and on survival targets simulated in Model 2. The amount of staff required as calculated by combining data on: dental service needs, activity standards for dental services, workload components in dental care, cost per working hour of dental staff, and probabilities of clinical deterioration in the wait for dental visits. Main Findings: In Model 1 (wait times determined by experts), survival probabilities were found to be unevenly distributed between diagnostic categories: category 4= 0.939 (SE 0.019); category 3= 0.829 (SE 0.035); category 2= 0.351 (SE 0.061) and category 1= 0.120 (SE 0.044). The cost of dental staff in Model 1 was estimated to be R$104 110.88 (BRL). In cost simulations of Model 2, where wait times were derived from the survival analysis study, a similar 0.900 survival probability target for all sampled quadrants (n=7 376) was found regardless of their final classification in the study year. The resulting cost of Model 2 was R$99 305.89 (BRL). Conclusions: From an equity-access perspective, the survival analysis concluded that wait times for dental visits determined by the experts may engender inequitable survival probabilities for oral quadrants classified in different diagnostic categories. From a dental-staff costs perspective, one concluded that less resources were required by setting an equitable 90% survival target for all oral quadrants studied

Equidade de acesso à atenção básica em saúde bucal

The objective of this study was to demonstrate face validity with a novel resource allocation framework designed to maximize equity into dental booking systems. The study was carried out in 2014. Eleven experts in primary dental care practice in Southern Brazil participated, using a three-round consensus group technique. First, the experts reached consensus on the items to be included in a 5-level diagnostic scale. They identified 21 clinical conditions and categorized them according to the oral health intervention required. Then, they described workload and activity standards for dental staff to carry out health promotion, oral disease prevention, dental treatment, dental rehabilitation, and urgent dental care. Finally, they agreed upon a set of wait times for primary dental care, establishing maximum waits from 2 to 365 days, according to the diagnostic classification. The framework demonstrated potential ability to promote more equitable access to primary dental services, since equal diagnostic classifications share the same waiting times for the dental care they require.O objetivo do estudo foi demonstrar validade de face com uma nova matriz destinada a maximizar a equidade nos sistemas de agendamento odontológico. O estudo foi realizado em 2014, no qual participaram 11 dentistas com experiência de trabalho na rede básica de saúde da região sul do Brasil, utilizando a técnica de grupo de consenso em três rodadas de discussão. Primeiro, os participantes chegaram ao consenso quanto aos itens que deveriam estar presentes em uma escala de classificação diagnóstica de 5 níveis. Identificaram 21 condições clínicas de saúde bucal e as categorizaram conforme a intervenção necessária. A seguir, os participantes descreveram as cargas de trabalho e os padrões de atividade recomendados para a equipe odontológica realizar promoção da saúde, prevenção de doenças bucais, tratamento odontológico, reabilitação dentária, e atendimento odontológico de urgência. Por último, os dentistas chegaram ao consenso sobre tempos máximos de espera para atendimento odontológico na rede básica, estabelecendo prazos de 2 até 365 dias conforme a classificação diagnóstica atribuída. Este estudo demonstrou o potencial da matriz de alocação de recursos para promover acesso mais equitativo aos serviços odontológicos da rede básica, uma vez que classificações diagnósticas iguais compartilham os mesmos prazos de espera para o atendimento odontológico requerido

Occurrence of dental emergency events in primary health care services

The aim of this study was to describe the occurrence of dental emergency and its association with individual factors and primary health care services. A follow-up study was conducted with data extracted from an exploratory study about the classification of dental care needs over time according to a care framework. There were included 1831 patients of five services. The outcome was the occurrence of dental emergency analyzed according to sex, age, skin color, service and maximum waiting time for dental care. A multivariate analysis with Poisson regression was used to estimate weighted prevalence ratio (PR) with 95% Confidence Intervals (CI) and survival analysis was conducted. The prevalence of dental emergency was 12.6%, varying according to age (13–19: PRa =1.79 (95%CI: 1.0–3.21); 20–65: PRa = 2.71 (95%CI: 1.73–4.26); Over 65: PRa = 2.51 (95%CI: 1.41–4.46)) and Primary Health Care service (FHS 2: PRa = 2.20 (95%CI: 1.37–3.53), FHS 3: PRa = 1.43 (95%CI: 0.90–2.27); FHS 4: PRa = 3.25 (95%CI: 2.15–4.92), FHS 5: PRa = 2.49 (95%CI: 1.56–3.97)) For 231 cases classified as emergency, the failure rate was 7.4%. For 214 cases of emergency, the non-continuity after appointment rate was 53.7%. The incidence of dental emergency was 8.3% and recurrence was 7.2%. Considering all 262 emergency cases attended, the resolution rate was 93.5% and most cases (n = 252, 96.1%) received care within one day. The results point to high effectiveness in emergency dental care within Primary Health Care services. There are indications of the need for improvements in retention and continuity of care

El cuidador familiar en lo centro del programa de la atención domiciliar de una unidad básica de salud del municipio de Porto Alegre

El objetivo de este estudio fue conocer las estrategias que cuidadores familiares de usuarios del Programa de Asistencia Domiciliar de una Unidad Básica de Salud del Municipio de Porto Alegre/RS utilizan para cuidar de sí y evaluar el grado de sobrecarga en relación a su condición de cuidador. Estudio cualitativo, descriptivo y exploratorio, que contó con la participación de nueve sujetos. Las informaciones fueron colectadas a través de entrevista semi-estructurada y evaluadas por técnica de analice de contenido, a partir de tres temas: Cuidando de su enfermedad, Cuidador y la Salud Mental y Cuidador y el Cuidado Integral. Para evaluar el nivel de sobrecarga de los cuidadores fue utilizado el instrumento Zarit-Burden Interview. Debido a la sobrecarga de los cuidadores, su inclusión en la agenda de cuidados del equipo de salud se hace necesaria para evitar prejuicios relacionados a la salud de esos sujetos y de sus familiares.Descriptores: asistencia domiciliar, relaciones familiares, atención primaria a la salud

Perceptions of the bearers of HIV/AIDS before the inability to breastfeeding

Objetivo: Conhecer as percepções das portadoras de HIV/aids perante impossibilidade de amamentação. Métodos: Trata-se de estudo qualitativo descritivo e exploratório realizado em um Hospital Dia, de referência no estado de Santa Catarina, em 2012. A técnica de coleta utilizada foi à entrevista semi-estruturada aberta conforme Minayo1. Resultados: Os sujeitos de pesquisa apresentaram faixa etária predominante foi entre 27 a 38 anos. A experiência de não amamentar, foi para as mulheres uma experiência penosa e emocionalmente desgastante, e criaram um modo de satisfazer a amamentação simbólica idealiza da por elas durante o ato de amamentar, substituindo o significado da amamentação fisiológica. Conclusão: Deste modo, a enfermagem precisa além do cumprimento de protocolos a respeito da inibição da lactação, compreender e estimular a amamentação simbólica, criada pelas mulheres, além dos aspectos biológicos, os emocionais, sociais e culturais que circundam a mulher.&nbsp

Perceptions of the bearers of HIV/AIDS before the inability to breastfeeding

Objetivo: Conhecer as percepções das portadoras de HIV/aids perante impossibilidade de amamentação. Métodos: Trata-se de estudo qualitativo descritivo e exploratório realizado em um Hospital Dia, de referência no estado de Santa Catarina, em 2012. A técnica de coleta utilizada foi à entrevista semi-estruturada aberta conforme Minayo1. Resultados: Os sujeitos de pesquisa apresentaram faixa etária predominante foi entre 27 a 38 anos. A experiência de não amamentar, foi para as mulheres uma experiência penosa e emocionalmente desgastante, e criaram um modo de satisfazer a amamentação simbólica idealiza da por elas durante o ato de amamentar, substituindo o significado da amamentação fisiológica. Conclusão: Deste modo, a enfermagem precisa além do cumprimento de protocolos a respeito da inibição da lactação, compreender e estimular a amamentação simbólica, criada pelas mulheres, além dos aspectos biológicos, os emocionais, sociais e culturais que circundam a mulher.

Equidade de Acesso à Atenção Básica em Saúde Bucal

The objective of this study was to demonstrate face validity with a novel resource allocation framework designed to maximize equity into dental booking systems. The study was carried out in 2014. Eleven experts in primary dental care practice in Southern Brazil participated, using a three-round consensus group technique. First, the experts reached consensus on the items to be included in a 5-level diagnostic scale. They identified 21 clinical conditions and categorized them according to the oral health intervention required. Then, they described workload and activity standards for dental staff to carry out health promotion, oral disease prevention, dental treatment, dental rehabilitation, and urgent dental care. Finally, they agreed upon a set of wait times for primary dental care, establishing maximum waits from 2 to 365 days, according to the diagnostic classification. The framework demonstrated potential ability to promote more equitable access to primary dental services, since equal diagnostic classifications share the same waiting times for the dental care they requir

Measurement of the top quark forward-backward production asymmetry and the anomalous chromoelectric and chromomagnetic moments in pp collisions at √s = 13 TeV

Abstract The parton-level top quark (t) forward-backward asymmetry and the anomalous chromoelectric (d̂ t) and chromomagnetic (μ̂ t) moments have been measured using LHC pp collisions at a center-of-mass energy of 13 TeV, collected in the CMS detector in a data sample corresponding to an integrated luminosity of 35.9 fb−1. The linearized variable AFB(1) is used to approximate the asymmetry. Candidate t t ¯ events decaying to a muon or electron and jets in final states with low and high Lorentz boosts are selected and reconstructed using a fit of the kinematic distributions of the decay products to those expected for t t ¯ final states. The values found for the parameters are AFB(1)=0.048−0.087+0.095(stat)−0.029+0.020(syst),μ̂t=−0.024−0.009+0.013(stat)−0.011+0.016(syst), and a limit is placed on the magnitude of | d̂ t| < 0.03 at 95% confidence level. [Figure not available: see fulltext.