ABSTRACT Objective: Obstructive sleep apnea (OSA) is a highly prevalent chronic disease, associated with morbidity and mortality. Although effective treatment for OSA is commercially available, their provision is not guaranteed by lines of care throughout Brazil, making legal action necessary. This study aimed at presenting data related to the volume of legal proceedings regarding the access to diagnosis and treatment of OSA in Brazil. Methods: This was a descriptive study of national scope, evaluating the period between January of 2016 and December of 2020. The number of lawsuits was analyzed according to the object of the demand (diagnosis or treatment). Projections of total expenses were carried out according to the number of lawsuits. Results: We identified 1,462 legal proceedings (17.6% and 82.4% related to diagnosis and treatment, respectively). The projection of expenditure for OSA diagnosis in the public and private spheres were R$575,227 and R$188,002, respectively. The projection of expenditure for OSA treatment in the public and private spheres were R$2,656,696 and R$253,050, respectively. There was a reduction in the number of lawsuits between 2017 and 2019. Conclusions: Legal action as a strategy for accessing diagnostic and therapeutic resources related to OSA is a recurrent practice, resulting in inefficiency and inequity. The reduction in the number of lawsuits between 2017 and 2019 might be explained by the expansion of local health care policies or by barriers in the journey of patients with OSA, such as difficulties in being referred to specialized health care and low availability of diagnostic resources.

RESUMO Objetivo: A apneia obstrutiva do sono (AOS) é uma doença crônica altamente prevalente, associada a morbidade e mortalidade. Embora tratamentos efetivos para a AOS estejam disponíveis comercialmente, seu fornecimento não é garantido pelos fluxos de atendimento em todo o Brasil, tornando necessária a judicialização. Este estudo teve como objetivo apresentar dados referentes ao volume de processos judiciais relacionados ao acesso ao diagnóstico e tratamento da AOS no Brasil. Métodos: Estudo descritivo de abrangência nacional, avaliando o período entre janeiro de 2016 e dezembro de 2020. O número de demandas judiciais foi analisado de acordo com o objeto da demanda (diagnóstico ou tratamento). As projeções das despesas totais foram realizadas de acordo com o número de demandas judiciais. Resultados: Foram identificados 1.462 processos judiciais (17,6% e 82,4% referentes a diagnóstico e tratamento, respectivamente). A projeção dos gastos com o diagnóstico da AOS nas esferas pública e privada foi de R$ 575.227 e R$ 188.002, respectivamente. A projeção dos gastos com o tratamento da AOS nas esferas pública e privada foi de R$ 2.656.696 e R$ 253.050, respectivamente. Houve redução do número de demandas judiciais entre 2017 e 2019. Conclusões: A judicialização como estratégia de acesso a recursos diagnósticos e terapêuticos relacionados à AOS é uma prática recorrente, resultando em ineficiência e iniquidade. A redução do número de demandas judiciais entre 2017 e 2019 pode ser explicada pela expansão das políticas locais de saúde ou por barreiras na jornada dos pacientes com AOS, como dificuldades de encaminhamento para atendimento especializado e a baixa disponibilidade de recursos diagnósticos.

The infant mortality rate is an indicator of quality of life, development, and quality and accessibility of health care. Improvements in science, technology and better access to health care have contributed to a major decrease in the infant mortality rate in Argentina. Since the 1980s, infant deaths have been classified based on the opportunities for reducibility yielded by scientific knowledge and available technologies, in order to obtain a basis for the monitoring and implementation of health policies. The last review of this classification was in 2011. In 2012, a total of 5,541 neonatal deaths (less than 28 days of life) were registered and, under this new classification, over 61% were reducible mainly by the improvement of perinatal health care and adequate and timely treatment of the at-risk newborn. In 2012, a total of2,686 post-neonatal deaths (from 28 days of life to a year) were registered and, under this new classification, over 66.8% were reducible by improving prevention strategies and providing adequate and timely treatment. This new analysis demonstrates the need to improve the opportunity, accessibility and quality of perinatal care starting at pregnancy, guaranteeing quality care at delivery and reinforcing prevention and timely treatment of common diseases in childhood over the first year of life.

La tasa de mortalidad infantil (TMI) es tanto un indicador de desarrollo y calidad de vida como de accesibilidad y calidad de los servicios de salud. Los desarrollos científicos y tecnológicos y las mejoras en la accesibilidad al sistema de servicios de salud han contribuido a la importante disminución de la tasa de mortalidad infantil en nuestro país. Desde la década del 80, se implementó el análisis de las defunciones infantiles, según las posibilidades de reducirlas de acuerdo con el conocimiento científico y la capacidad tecnológica disponible, con el fin de suministrar un insumo para la implementación y el monitoreo de políticas públicas. La última revisión de esta clasificación fue realizada en el año 2011. En el año 2012, se registraron 5541 defunciones neonatales (menos de 28 días de vida) y, según la última clasificación, 61% de estas defunciones hubieran podido reducirse, principalmente reforzando acciones de cuidado durante el período perinatal y en el tratamiento adecuado y oportuno del recién nacido. En el año 2012, se registraron 2686 defunciones posneonatales (entre 28 y 365 días de vida) y, según la última clasificación, 66,8% de estas defunciones hubieran podido reducirse, fortaleciendo la prevención y el tratamiento adecuados y oportunos. Esta nueva revisión evidencia la necesidad de mejorar la oportunidad, accesibilidad y calidad de la atención desde el embarazo, garantizando las condiciones de la atención del parto, y fortalecer la prevención y el tratamiento de la patología prevalente en el primer año de vida.

There are no field studies about the general pediatrician’s role in the third level of care. Garrahan Hospital is a high complexity pediatric hospital, organized under the criterion of progressive care. A matrix pattern-based organization model was implemented to solve the tension between the strong tendencies to specialization invading all areas of medicine, and the need of integrating medical actions. The model generated a crisis among general pediatricians working in the hospital. The objective of this study was to evaluate the different ideas of general pediatricians and specialists about their functions, opportunities and training to fulfil the requirements of their work in the new setting. Population, materials and methods. Qualitative research instruments were used in a case-study model. Individual interviews with a semi-structured questionnaire were administered to 25 pediatricians. Results. The interviewed physicians considered that the general paediatrician’s functions in a high complexity context are the care of patients with complex multisystemic illnesses, the organization of care of patients with chronic conditions, and the coordination of care and integration of actions during the period of hospitalization. However, they usually do not play the role of a bedside doctor. The general paediatrician acts also as a general consultant in ambulatory medicine. Conclusions. The professional crisis appears in a historical cross-road of two models of approach to medical problems and actions: the trend to specialization and the attempts to integrate knowledge. The convergence of a group of general pediatricians installed in a new hospital with a matrix patternbased organizational design, with new roles and responsibilities, produced a crisis of professional performance. They are still working in the process of generating a new profile: a general pediatrician specialized in polyvalent high complexity pediatrics. The young phisicians are working in a more interdisciplinary way.

Introducción. En la actualidad no existen trabajos de campo sobre el rol del clínico pediatra en el tercer nivel de atención. La organización del Hospital Nacional de Pediatría “Prof. Dr. Juan P. Garrahan”, según cuidados progresivos en salas polivalentes, generó interrogantes sobre el rol del clínico pediatra en el trabajo compartido con múltiples especialistas en la asistencia de alta complejidad. El objetivo del presente trabajo fue conocer las concepciones de clínicos pediatras y especialistas del Hospital Garrahan sobre las funciones, la oportunidad de la interconsulta y los conocimientos requeridos a los clínicos pediatras en ese contexto. Población, material y métodos. Se utilizaron métodos de investigación cualitativa, en un estudio de caso, a través de entrevistas individuales focalizadas semiestructuradas a 25 pediatras. Resultados. Según las concepciones de los entrevistados, las funciones del clínico pediatra en la alta complejidad incluyen el cuidado de pacientes complejos con enfermedades multisistémicas, la organización de la atención de pacientes crónicos y la coordinación de la asistencia e integración del conocimiento durante la internación; además, en el área ambulatoria funciona como consultor, pero no suele desempeñar el rol del médico de cabecera. Conclusiones. La crisis del rol del clínico en la alta complejidad se instala en un momento histórico en que coexisten las tendencias hacia la especialización y a la integración del conocimiento, en un modelo de organización hospitalaria que tiende al trabajo conjunto de clínicos pediatras y especialistas. Se está formando un nuevo clínico pediatra, entrenado en clínica polivalente de alta complejidad. Las generaciones más jóvenes realizan una asistencia cada vez más interdisciplinaria.