Strengths of primary healthcare regarding care provided for chronic kidney disease

ABSTRACT Objective: to assess the structure and results obtained by the "Chronic Renal Patients Care Program" in a Brazilian city. Method: epidemiological, cross-sectional study conducted in 14 PHC units and a secondary center from 2010 to 2013. The Donabedian Model was the methodological framework used. A total of 14 physicians, 13 supervisors, and 11 community health agents from primary healthcare were interviewed for the assessment of structure and process and 1,534 medical files from primary healthcare and 282 from secondary care were consulted to assess outcomes. Results: most units lacked sufficient offices for physicians and nurses to provide consultations, had incomplete staffing, and most professionals had not received proper qualification to provide care for chronic renal disease. Physicians from PHC units classified as capable more frequently referred patients to the secondary care service in the early stages of chronic renal disease (stage 3B) when compared to physicians of units considered not capable (58% vs. 36%) (p=0.049). Capable PHC units also more frequently presented stabilized glomerular filtration rates (51%) when compared to partially capable units (36%) and not capable units (44%) (p=0.046). Conclusion: patients cared for by primary healthcare units that scored higher in structure and process criteria presented better clinical outcomes. Objective: to identify the coping strategies of family members of patients with mental disorders and relate them to family member sociodemographic variables and to the patient's clinical variables. Method: this was a descriptive study conducted at a psychiatric hospital in the interior of the state of São Paulo, with 40 family members of hospitalized patients over the age of 18, and who followed the patient before and during hospitalization. We used tools to characterize the subjects and the Folkman and Lazarus Inventory of Coping Strategies. Results: the coping strategies most often used by family members were social support and problem solving. Mothers and fathers used more functional strategies (self-control p=0.037, positive reappraisal p=0.037, and social support p=0,021). We found no significant differences between the strategies and other variables examined. Conclusion: despite the suffering resulting from the illness of a dear one, family members make more use of functional strategies, allowing them to cope with adversities in a more well-adjusted way.


Introduction
The Brazilian health system is experiencing a situation characterized by high rates of morbidity and mortality caused by chronic conditions, among which the following stand out: type 2 diabetes mellitus, hypertension, chronic kidney disease (CKD), and cardiovascular diseases (1) .
Concomitantly, infectious diseases persist, along with the strong growth of external causes, which combine to form a complex epidemiological situation defined as "triple burden of disease" (2) .
Changes in the population's epidemiological profile are not properly heeded by the organization of the healthcare system so that inconsistency between the population's needs and the current healthcare model is observed (2) . Hence, coping with chronic conditions is a challenge faced by managers and professionals in all the fields of the healthcare system, as well as by patients.
Specifically in the case of CKD, severe problems still persist due to a low level of problem-solving capacity in primary healthcare (PHC) (3)(4) . Studies show that this disease is highly prevalent and mainly affects elderly individuals, hypertensive and diabetic patients, and is often under-diagnosed, untreated, or addressed only later on (5)(6) .
Data concerning the world population reveals that the prevalence of CKD is between 8% and 16% (6) . To date, there is no definitive information concerning the epidemiology of CKD in Brazil. Data obtained by a clinical laboratory in Juiz de Fora, MG, Brazil from 24,248 adult individuals when the disease was diagnosed using glomerular filtration rate (GFR) taking two creatinine blood test with a minimum interval of three months, revealed that 2.3% of the individuals presented CKD stages 3B, 4 or 5. If this percentage is extrapolated to the Brazilian adult population, an estimate of thee million individuals with CKD in advanced stage is obtained (7) .
The high prevalence of this disease associated with the complexity of its treatment results in the consumption of 10% of the annual budget of the Brazilian Ministry of Health, in addition to loss of productivity and of quality of life (8) .
Given the need to design new proposals to guide prevention strategies and the management of chronic diseases, the Ministry of Health has developed policies to reorganize the health services focusing on Integrated Health Services Networks. In Minas Gerais, this proposal was consolidated with the creation of the HIPERDIA Minas Program, characterized by the supply of care shared between PHC units and Hiperdia Centers (9) .
In this model, the PHC is the entry way to the health system and should monitor the entire path the patient goes through the network by using specific tools such as: clinical records, guidelines, a referral and counterreferral system, and effective communication strategies between PHC teams and specialists.
Understanding the complexity of care provided to patients with CKD and the role of PHC in the coordination of the Integrated Health Services Networks, this study's objective was to assess the structure, process, and results obtained by the Chronic Renal Patients Care Program in a Brazilian city. The instrument used (11) was originally designed for a normative assessment of the care provided to individuals with diabetes mellitus. This instrument was adapted for this study to allow the care provided to patients with CKD to be assessed. Indicators and actions were selected according to the "Guidelines for Care Provided to Chronic Kidney Disease" (12) .

Method
To analyze the capability of PHC units, scores were assigned to each criterion of the questionnaire and these scores were totaled within the structure or process' subcomponents. This way, we have two columns: one presenting the sum of the structure's subcomponents and another presenting the sum of the process's subcomponents for each interview. The structure dimension received a weight of 4 and the process dimension received a weight of 6. The scores obtained by the three interviewees in the subcomponents of both structure and process were totaled to reach a PHC unit's total score, which in turn represents a unit's capability. This score was then divided into terciles of classification and, based on the total scores, each PHC unit was classified as "capable", "partially capable", or "not capable", that is, these classifications concern the PHC units' capacity to implement preventive actions and monitor CKD.
A total of 1,534 medical files from PHC that corresponded to the micro-area of the physician interviewed were selected to be analyzed. These According to the progression of the GFR over the follow-up period, patients were classified as:non-progressing (GFR did not decrease); -slowly progressing (GFR decreased up to 5 mL/min/year);rapidly progressing (GFR decreased ≥5 mL/min/year).
Blood pressure was considered to be under control when systolic blood pressure was ≤ 140 mmHg and/ or diastolic blood pressure was ≤ 90 mmHg among hypertensive individuals. Those with diabetes should have their systolic blood pressure ≤ 130 mmHg and/or diastolic blood pressure ≤ 80 mmHg (13) .
The variables selected were pre-encoded and      (Figure 3). We also observed that most professionals were not specifically qualified to provide care to patients with CKD. In regard to this aspect, the obstacle most frequently mentioned by the units' managers was the low number of workers with the appropriate profile and technical qualification to enable the team's expansion process. Other factors, such as lack of social recognition, difficulties attending continuing education programs, poor working conditions, and difficulties faced in the management of the staff, also contribute to high turnover and consequent fragmentation of the network (14)(15) .
In addition to the structural and human resources deficiencies, weaknesses regarding the process were  (20) . Late referral was also observed in England, where approximately one quarter of the patients were referred to a specialist only one month before the need to initiate renal replacement therapy. Late referral was associated with a lower prevalence of preventive interventions, worse clinical status at the beginning of renal replacement therapy, longer hospitalizations, and lower survival rates (21) .
On the other hand, early referral of patients with CKD to the secondary care level is associated with a better prognosis. A recent study addressing 3,273 chronic patients at stages 3 to 5 verified that those referred to a nephrologist at advanced stages of the disease were at a greater risk of death before dialysis was initiated (22) .
In addition to early referral of patients to a specialist, a multidisciplinary approach to renal disease can lead to more satisfying outcomes. A recent study reports that the average annual decline in the glomerular filtration rate was twice as high among patients monitored by a nephrologist only compared to when the treatment was conducted by a multidisciplinary team (23) . Similar results were obtained in the Hiperdia Minas Center in Juiz de Fora from 934 patients received cared over a period of two years. The speed of annual GFR loss in this sample was reduced or stabilized in two thirds of the patients, suggesting the multidisciplinary team was efficient in managing CKD (24) . Even though a single city was addressed in this study, which can be considered one of this study's limitation, the results can support the sensitization of managers concerning the need to invest in the qualification of professionals and in management tools, coupled with a care plan that is shared between PHC and a multidisciplinary team, factors that can positively impact the care provided to individuals with CKD (25) . to screen for CKD (12)(13)16) .
Failure to comply with these guidelines when monitoring CKD is not limited to the state of Minas Gerais. Other authors list severe deficiencies in the management of renal disease within the PHC sphere.
A study conducted in the south of Brazil reports that only 8% of diabetic patients and 5% of hypertensive patients had their GFR assessed by physicians in the PHC service (17) . In the state of São Paulo, records of microalbuminuria were found in only 1.4% of the medical files (18) .
Another study conducted in the United States reports that 64% of PHC physicians report a lack of knowledge concerning criteria used to refer patients to specialized care services and 16% were not able to estimate a patient's glomerular filtration rate. The same study shows that 53% of the nephrologists interviewed believed that PHC physicians were late in referring patients to specialized assessment (3) .
Late referral of patients with CKD implies increased risk of mortality, worse metabolic status in dialysis, complications related to the use of temporary vascular access, longer hospitalizations, more difficult access to preemptive kidney transplantation, and a consequent increase in health services costs (5,19) .
A retrospective study conducted in a dialysis center

Conclusion
This study showed that the PHC units with higher scores concerning structure and process presented better clinical outcomes regarding the care provided to CKD, characterized by earlier referrals and lower declines in patient GFR rates.
These findings suggest that the healthcare network is more efficient in providing care to chronic renal patients when PHC services develop appropriate clinical management processes, characterized by preventive, management and treatment actions directed to CKD.