A utilização e prescrição de medicamentos para idosos em Juiz de Fora

-Desde meados do século passado vem sofrendo incremento crescente o contingente de idosos, no Brasil, estimando-se, segundo o IBGE que os maiores de 60 anos, que já eram 18 milhões em 2005, alcançarão 25 milhões em 2020, representando 11,4% dos previstos 219 milhões de brasileiros, A Transição demográfica, que se faz acompanhar de concomitante mudança no perfil das doenças (Transição Epidemiológica), teve início no Brasil, bem mais tardiamente, quando comparada ao que ocorreu nos países desenvolvidos. O envelhecimento de uma população, considerado sob o ponto de vista demográfico, é o resultado da manutenção por um período de tempo razoavelmente longo de taxas de crescimento da população idosa superiores às da população mais jovem. No caso brasileiro, isso foi resultado da rápida queda da fecundidade iniciada na segunda metade dos anos 1960, que foi precedida em pelo menos 30 anos por altos níveis de fecundidade concomitante a uma queda gradual da mortalidade. O objetivo do estudo foi identificar algumas características da utilização de medicamentos por idosos bem como apreender o grau de informação dos prescritores, sobre as peculiaridades e cuidados requeridos por esse tipo de pacientes (segunda etapa do Projeto). Para tanto foi realizado um Estudo de Corte Transversal ou de Prevalência, A amostra foi probabilística, sistemática, tendo como referencial clientela envolvida nos programas desenvolvidos pelo Departamento de Atenção à Terceira Idade da Prefeitura Municipal de Juiz de Fora, com idade de 60 anos ou mais, excluindo os que apresentaram déficit cognitivo, de concentração ou de memória. Do total de 373 entrevistados, a grande maioria, 264 (70,8%) pertence ao sexo feminino e 84,4% tinham entre 60 e 80 anos (42,6%, entre 60 e 70 anos e 41,8%, entre 71 e 80 anos), sendo a média de idade igual a 72,3 anos.. Quase todos (99%) moram com a família, sendo que 77,7% são aposentados. Em relação à renda familiar, 17,8% auferem até um salário mínimo, 68,2%, entre 2 e 4,9 e 12,7%, entre 5 a 9,9 salários mínimos. A maioria absoluta (359, isto é, 96,2%) dos entrevistados faziam uso de algum medicamento (entre 3 e 5, com uma mediana de 3 e um total de 1.260 diferentes medicamentos estavam em uso. Os antihipertensivos ocuparam lugar de destaque, representando 46,7% do total, seguidos de longe, pelos analgésicos e antiinflamatórios (8,69%), ansiolíticos e antidepressivos (6,76%,) e hipolipemiantes (5,87). 44% afirmou que fazia uso de plantas medicinais e apenas 38 (10,3%) declarou que fazia uso regular de vitaminas. Indagados se costumavam tomar medicamentos sem prescrição médica, 175 (47%) afirmaram que o faziam, tendo como justificativa: conhecimento sobre o medicamento (70,3%), e em proporção bem menor dificuldades no aceso aos serviços de saúde (3,4%), falta de tempo para ir ao médico (2,9%), motivos financeiros (1,7%). Os idosos, pelas doenças e incapacidades inerentes á longevidade, tendem a demandar mais assistência sanitária e a utilizar mais medicamentos tanto a partir da prescrição médica, como através da automedicação. Ao uso, racionalmente justificado, certamente, vem somar-se aquele, inadequado e desnecessário, resultante da tendência medicalizadora da sociedade moderna, fenômenos confirmados pelo presente estudo, tendo se evidenciado a presença da polifarmácia e da automedicação

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research