Challenges for performance assessment and improvement in primary health care: the case of the Portuguese health centres

Primary care is currently at the heart of health service policy, both in Portugal and internationally. At the same time, interest in the measurement of efficiency of health care delivery has increased considerably. However, very few studies have focused specifically on performance assessment in primary health care provision. In this paper we aim to contribute to a discussion regarding appropriate ways to compare the performance of primary health care providers. Following a review of the literature, a conceptual framework for performance assessment of health centres is developed and tested using the Portuguese case. Our empirical analysis uses data from 2004 and 2005 for all the Portuguese health centres and compares the geographical equity of access to services, technical efficiency and quality of services across District Health Authorities. Data Envelopment Analysis is the technique used to measure technical efficiency. From our empirical analysis, we conclude that there is evidence of large variation in equity of access to services, in technical efficiency and quality of services across District Health Authorities. Our findings suggest that a better use of resources could lead to more and improved services. Whilst formative evaluation could contribute to this, the challenge is to engage health care professionals in the evaluation exercise

On the need for reform of the portuguese judicial system - does data envelopment analysis assessment support it?

The Portuguese judicial system has attracted considerable criticism in recent years and demands for reforms have gained prominence. By using the Data Envelopment Analysis technique and focusing on the performance of 223 Portuguese first instance courts during the period of 2007 to 2011, this research has found evidence that supports some of this criticism and justifies the calls for reforms, better performance and accountability of the judicial system. In particular, our results found a sector with considerable scope for improvement with less than 16 percent of the 223 courts analysed making an efficient use of their resources in each year and with only one third of the courts being considered efficient in at least one of the five years assessed. Whilst the results suggest that improvement can be achieved with better case management, scale factors also seem to play an important role in explaining inefficiency, with most of the inefficient courts being smaller than optimal and with smaller courts being, on average, less efficient than larger ones. The existence of a statistically significant relationship between courts’ efficiency and size was confirmed by the Mann-Whitney test. These results indicate considerable scope for improvement and that some of the planned reforms are timely and seem well targeted. However, the results also suggest that efficiency increases matching peers’ best practices are not enough to sustainably reduce the prevailing judicial backlog and length of court proceedings in a considerable number of courts. Major changes in the capacity and/or functioning of the Portuguese judicial system might also be required

Detection of outliers in multivariate data: a method based on clustering and robust estimators

Outlier identification is important in many applications of multivariate analysis. Either because there is some specific interest in finding anomalous observations or as a pre-processing task before the application of some multivariate method, in order to preserve the results from possible harmful effects of those observations. It is also of great interest in supervised classification (or discriminant analysis) if, when predicting group membership, one wants to have the possibility of labelling an observation as does not belong to any of the available groups. The identification of outliers in multivariate data is usually based on Mahalanobis distance. The use of robust estimates of the mean and the covariance matrix is advised in order to avoid the masking effect (Rousseeuw and Leroy, 1985; Rousseeuw and von Zomeren, 1990; Rocke and Woodruff, 1996; Becker and Gather, 1999). However, the performance of these rules is still highly dependent of multivariate normality of the bulk of the data. The aim of the method here described is to remove this dependence

Alimentação e Hipertensão Arterial em Portugal

É atualmente consensual que alterações no estilo de vida podem reduzir a pressão arterial, nomeadamente a restrição salina na dieta, o consumo moderado de bebidas alcoólicas, o maior consumo de dietas ricas emhortofrutícolas, a manutenção do peso corporal entre outros.Com base nos dados disponíveis da prevalência da hipertensão arterial, sobrecarga ponderal e obesidade, consumo de álcool, gestão de sal e disponibilidades alimentares em Portugal, conclui-se pela necessidade deimplementar medidas de âmbito populacional para o controlo da pressão arterial

Investigação experimental e por elementos finitos para a determinação comparativa de tenacidade à fratura e espessura de camada mínima em bimateriais odontológicos (cerâmica odontológica e NiCr, Al2O3 e ZrO2)

O objetivo deste estudo é avaliar comparativamente a tenacidade à fratura das interfaces NiCr/cerâmica de recobrimento, alumina/cerâmica odontológica de recobrimento e zircônia/cerâmica de recobrimento, investigando a propagação de uma trinca interfacial sob uma ampla gama de misturas de modo de fratura. O efeito das propriedades mecânicas de cada material isolado e da interface, na iniciação da trinca e o caminho da trinca, também são estudados. O método dos elementos finitos (MEF) foi utilizado para calibrar a produção das amostras experimentais, permitindo obter as dimensões e quantidades mínimas de material necessárias para caracterizar corretamente o evento da fratura. Os espécimes foram testados até a falha usando uma máquina de ensaio de flexão de três pontos. Os parâmetros de fratura da interface foram obtidos usando o MEF. Para todos os espécimes, as trincas propagaram-se na cerâmica de recobrimento. Os resultados sugerem que, nas estruturas de bimaterais NiCr/cerâmica de recobrimento, alumina/cerâmica de recobrimento e zircônia/cerâmica de recobrimento, a cerâmica de recobrimento é mais frágil do que a interface, o que explicaria a constatação clínica de que a taxa de lascamento da cerâmica é maior do que a taxa de delaminação da interface. Consequentemente, um material cerâmico com uma maior resistência à fratura é necessário para diminuir a taxa de falha de restaurações de cerâmica.The objective of this study is to comparatively evaluate the fracture toughness of NiCr/veneering ceramic, alumina/veneering ceramic and zirconia/veneering ceramic interfaces by investigating the propagation of an interfacial crack under a wide range of mixed mode. The effect of the mechanical properties of the base materials and the interface, on the crack initiation and crack path, will also be studied. The finite element method (FEM) was used to calibrate the production of the experimental specimens, allowing to obtain the minimum dimensions and amounts of material needed to correctly characterize the fracture event. The specimens were tested to failure using a three-point bending test machine. Interface fracture parameters were obtained using the FEM. For all specimens, the cracks propagated in the veneering ceramic. The results suggest that, in the structures of bimaterial NiCr/veneer ceramic, alumina/veneer ceramic and zirconia/veneer ceramic, the veneer ceramic is brittle than the interface, which would explain the finding clinical evidence that the ceramic chipping rate is greater than the interface delamination rate. Consequently, a ceramic material with a higher fracture strength is needed to decrease the failure rate of ceramic restorations

Risco de erosão para diferentes cenários de evolução do litoral de Aveiro

Mestrado em Engenharia CivilAs zonas costeiras e o seu delicado equilíbrio está actualmente em risco como consequência da intensa utilização destes espaços, designadamente pelos usos artificializados do território. Ainda que devido à fragilidade que lhes está atribuída, pela forte exposição às acções energéticas do mar, as zonas costeiras apresentam desde sempre um papel preponderante nas sociedades. A intensificação do crescimento populacional nas áreas costeiras, a ampliação das áreas industriais, os impactos das actividades antrópicas levadas a cabo nas bacias hidrográficas e das intervenções de defesa costeira, o crescimento do turismo balnear e as alterações climáticas entre outros factores, constituem os principais problemas destas áreas litorais. Desta forma torna-se cada vez mais importante conhecer os fenómenos que intervêm na evolução da linha de costa, para a quantificação e mapeamento do risco em função das intervenções. Assim, nesta dissertação, após identificados os principais fenómenos associados às alterações climáticas, e recorrendo-se à modelação numérica simularam-se diferentes cenários da evolução da costa e analisaram-se os resultados obtidos para fundamentar a elaboração de mapas de risco do litoral de Aveiro.Coastal areas and his delicate balance are currently in risk, as result of the intense use of those spaces, through a strong artificialization of this territory. Although the fragility that is assigned to these areas, by the high exposure to energetic activities of the sea, the coastal areas have always had a predominant role in societies. The increase population in coastal areas, the expansion of industrial areas, the impacts of human activities developed in river basins, the coastal defense interventions, the growth of seaside tourism and climate change among other factors, are the main problems associated at coastal areas. So, it becomes increasingly important, to understand the events involved in the evolution of the shoreline, quantify and map the risk associated with the interventions in coastal areas. In this dissertation, were identified the main events related with climate changes, and using numerical modeling were simulated different scenarios of the evolution of the shoreline. With the results obtained with modeling it was possible to support the development of risk maps from Aveiro coastal areas

Bolachas sem glutén: desenvolvimento da formulação e processo de fabrico

RESUMO O presente relatório foi realizado no âmbito do Estágio Profissionalizante para obtenção do grau de Mestre em Engenharia Alimentar, da Escola Superior Agrária do Instituto Politécnico de Coimbra. O estágio decorreu na empresa Paupério Distribuição, Lda. e teve a duração de 6 meses, de Janeiro a Julho de 2015. Devido ao número crescente em Portugal de doentes celíacos, intolerantes ao glúten, torna-se necessário que as indústrias alimentares consigam dar resposta às necessidades alimentares destas pessoas aumentando as suas alternativas para uma dieta isenta de glúten. Assim, o principal objetivo deste estágio consistiu no estudo, desenvolvimento e produção de um tipo de bolacha sem glúten numa unidade fabril que se dedica à produção de bolachas convencionais e cujas linhas de produção incorporam alguns equipamentos bastante antigos. A formulação da bolacha sem glúten foi efetuada tendo por base uma receita própria da empresa, onde a farinha de trigo, matéria-prima comum a todas as bolachas convencionais produzidas na empresa, foi substituída integralmente por outras matérias- primas isentas de glúten, tais como a farinha de arroz, farinha de milho branco T70 e amido de milho. Os restantes ingredientes da formulação original mantiveram-se. Realizaram-se no total três ensaios industriais. O primeiro ensaio realizado teve por intuito perceber a opinião dos consumidores face ao produto a desenvolver e fazer os ajustes necessários à formulação de partida e ao próprio processo de fabrico. O segundo ensaio industrial, que já contemplou os ajustes da primeira formulação, permitiu obter uma bolacha mais apelativa para o consumidor. No entanto, quer a consistência quer o sabor da bolacha foram ainda otimizados numa terceira formulação/ensaio onde se adicionaram goma xantana e farinha de milho branco T70. Os produtos obtidos dos três ensaios industriais foram estudados a nível sensorial através de inquéritos realizados aos colaboradores da empresa. Dos resultados obtidos verificou-se que a formulação com farinha de milho branco T70 e goma xantana foi a que resultou melhor. A goma xantana é um aditivo natural que funciona bem nas massas que não contêm glúten, pois aumenta a sua extensibilidade proporcionando o mesmo efeito que as proteínas do glúten nas receitas com farinha de trigo. As bolachas dos dois últimos ensaios foram submetidas a um teste de quantificação de glúten por um laboratório acreditado. A técnica de quantificação utilizada foi a de iii ELISA, e de acordo com os resultados obtidos constatou-se que nenhuma das bolachas desenvolvidas poderia ter inscrita na embalagem a informação “isenta de glúten” por apresentarem valores superiores a 20 mg/kg. No entanto, a bolacha do último ensaio apresentou uma concentração de 70 mg/kg e neste caso poderia incluir a inscrição “teor muito baixo de glúten”. Ressalve-se que os ensaios foram realizados nas linhas de produção usadas para as bolachas convencionais, e apesar das operações de limpeza realizadas, é difícil de garantir a inexistência de vestígios de glúten nas novas formulações. A alternativa será a criação de uma nova linha produtiva dedicada exclusivamente à elaboração de produtos sem glúten. O custo de produção da bolacha sem glúten foi analisado para o ensaio que melhor aceitação teve por parte dos inquiridos. O valor obtido foi de 6.79 € comparativamente ao custo de produção da bolacha da receita base usada (4.20 €). Palavras-chave: glúten, doentes celíacos, bolacha, farinha de arroz, farinha de milho branco T70, amido de milho, análise sensorial. iv ABSTRACT This work has been developed for the internship program of the Master’s in Engenharia Alimentar (Food Sciences and Engineering) at Escola Superior Agrária do Instituto Politécnico de Coimba. The internship took place at Paupério Distribuição, Lda. and was six months long, from January to July 2015. Nowadays, due to the ever growing number of people with celiac disease (gluten intolerance) in Portugal, food industries find it necessary to come up with ways of fulfilling this type of eating needs by increasing the available alternatives for a gluten free diet. So, the main goal of this internship was the study, development and production of a gluten free cookie that would be produced at a manufacturing facility fitted with somewhat old equipment used for the production of traditional cookies and biscuits. Formulation of the gluten free cookie was based on one of the company’s own recipes, in which wheat flour, the main ingredient in the company’s cookies, has been completely replaced by other gluten free raw materials, such as rice flour, white corn flour T70 and maize starch. All the other ingredients of the original formulation were kept. In total, three industrial trials were conducted. The first one aimed at understanding consumers’ opinions towards the product under development and make any necessary adjustments to the starting formulation and the production process itself. The second industrial trial, in which the first formulation’s adjustments were included, enabled the creation of a much more appealing cookie for the consumer. However, both the consistency and the flavour of the cookie were optimised through the third formulation/trial where xanthan gum and white corn flour T70 were added. Products obtained from the three trials were studied at a sensory level through surveys. From the surveys’ results, it was possible to ascertain that the formulation with the xanthan gum and white corn flour T70 was the best. The xanthan gum is a natural additive that works well with gluten free dough, as it improves its extensibility, while providing the same effect as proteins in recipes with wheat flour. Cookies from the two last trials were submitted to gluten quantification tests on a qualified laboratory. The quantification technic used by ELISA, and according to the results obtained, it was possible to verify that none of the cookies produced could be labelled as “gluten free” as they had values of over 20 mg/kg. Nevertheless, the cookie v from the last trial presented a value of 70 mg/kg, hence, it could be labelled as “very low gluten”. It should be noted that the trials were conducted in the same production lines used for traditional cookies and, in spite of the cleaning operations, it is difficult to ensure that there are no traces of gluten from previous production in the new formulations. Alternatively, a new production line could be created exclusively for the production of gluten free products. The production cost of gluten free cookie was analyzed for the test that had better acceptance by the respondents. The value obtained was € 6.79 compared to the formulation of cookie production cost base used (€ 4.20). Keywords: gluten, celiac patients, cookie, rice flour, white corn flour T70, maize starch, sensory analysis