Assessment of the scope of practice of physicians participating in the <i>Mais Médicos</i> (More Doctors) Program, and associated factors

Girardi, Sábado Nicolau; Carvalho, Cristiana Leite; Pierantoni, Célia Regina; Costa, Juliana de Oliveira; Stralen, Ana Cristina de Sousa van; Lauar, Thaís Viana; David, Renata Bernardes

doi:10.1590/1413-81232015219.15912016

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Article • Ciênc. saúde colet. 21 (09) • Sept 2016 • https://doi.org/10.1590/1413-81232015219.15912016 copy

Assessment of the scope of practice of physicians participating in the Mais Médicos (More Doctors) Program, and associated factors

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

The purpose of this study was to characterize the scope of practice of physicians working in primary healthcare participating in the Mais Médicos (More Doctors) Program (‘PMM') and investigate the factors associated with execution of a larger number of clinical activities. It is an exploratory study carried over January to March 2016, through a self-applied questionnaire containing a list of 49 procedures, activities and actions carried out in primary healthcare. A total of 1,241 physicians took part in the study, most of them female, between age 40 and 49, and of Cuban nationality. The physicians carried out an average of 22.8 ± 8.2 procedures; they reported knowing how to carry out a larger number of procedures. Factors associated with executing a larger number of procedures were: being male, having graduated more recently, two years or less practicing in their primary healthcare unit, practicing in the North or South geographical regions, in small towns and more distant from the regional health headquarters. The main reason for not carrying out the procedures and activities that they reported knowing how to do was the lack of materials and inadequate infrastructure. The results show that the scope of practice of the physicians of the PMM is lower than their capacities, and that interventions with the intention of widening their scope are necessary.

Key words
Mais Médicos Program; Human resources; Primary healthcare

Characteristic		n^* * Excluding missing data.	%
Gender
	Female	643	52.3
	Male	586	47.7
Age group (years)
	20–29	38	3.1
	30–39	379	30.9
	40–49	488	39.8
	50–59	281	22.9
	60 or over	39	3.3
Nationality
	Brazilian	227	18.5
	Cuban	906	73.8
	Other	94	7.7
Country of training
	Brazil	153	12.5
	Outside Brazil	1071	87.5
Years since graduation
	0–5	139	11.5
	6–10	186	15.3
	11–15	150	12.4
	11–15	170	14.0
	21–25	309	25.5
	26 or more	258	21.3
Specialist qualification?
	Yes	1075	86.6
	No	166	13.4
Time in primary health care
	≤ 8 years	582	47.1
	> 8 years	653	52.9
Time in this primary health unit
	≤ 2 years	719	58.4
	> 2 years	513	41.6
Location of unit: Region of Brazil
	North	137	11.0
	Northeast	540	43.5
	Southeast	304	24.5
	South	183	14.8
	Center-West	76	6.1
Scale of municipality where you work
	State capital or metropolitan region	292	23.5
	Population: Over 100,000	166	13.4
	Population: 50,000 – 100,000	140	11.3
	Population: 20,000 – 50,000	272	21.9
	Population: 10,000 – 20,000	221	17.8
	Population: Up to 10,000	150	12.1
Road journey time to health region HQ
	Up to 15 minutes	448	36.1
	16–30 minutes	126	10.2
	31–45 minutes	186	15.0
	45–60 minutes	118	9.5
	61–120 minutes	253	20.4
	Over 120 minutes	110	8.9

Health procedures, activities and actions	Have executed in the unit		Know how to execute
Health procedures, activities and actions	n^* * Excluding missing data.	%	n^* * Excluding missing data.	%
Treatment of anemia	1,215	99.6	1,219	99.9
Treatment of skin mycoses	1,219	99.5	1,223	99.8
Treatment of dermatitis	1,214	99.3	1,219	99.8
Treatment of back pain	1,203	98.8	1,213	99.7
Treatment of epigastralgia / peptic ulcer	1,205	98.8	1,215	99.6
Treatment of recurrent urinary infection	1,206	98.7	1,217	99.6
Treatment of asthma	1,196	98.7	1,209	99.8
Treatment of recurrent sinusitis	1,178	97.0	1,200	98.8
Low-risk prenatal treatment	1,174	96.2	1,217	99.7
Treatment of allergic kidney conditions	1,163	95.5	1,186	97.4
Order fecal occult blood test	1,152	95.1	1,204	99.4
Treatment of recurrent otitis	1,148	94.9	1,187	98.1
Complaints of red eyes	1,045	87.9	1,139	95.8
Treatment of superficial wounds	936	79.5	1,168	99.2
High-risk prenatal treatment	707	59.9	1,076	91.2
Removal of earwax	660	57.7	1,096	95.9
Intramuscular injection	654	56.7	1,139	98.7
Subcutaneous injection	617	54.0	1,128	98.8
Loss of sharp vision (refraction, glaucoma, retinopathy, cataract)	566	49.1	791	68.7
Oxygen therapy	566	49.1	1,116	96.8
Visual acuity screening	530	46.3	895	78.2
Papanicolau test	528	45.3	1,121	96.2
Infiltration of local anesthetic	506	44.8	1,096	97.1
Sutures	502	43.5	1,147	99.5
Removal of unwanted body from the ear	478	42.3	1,042	92.2
Incision and drainage of abscess	464	40.7	1,112	97.6
Vein puncture	443	39.5	1,048	93.5
Removal of unwanted body from legs, arms and extremities	368	32.9	992	88.7
Immobilization of wounded extremities	361	32.2	1,054	93.9
Drainage of paronychia	346	31.1	964	86.5
Insertion of urethral catheter	337	29.7	1,028	90.7
Immobilization of fractures	317	28.3	975	87.1
Removal of skin lesions	314	28.2	935	84.0
Removal of unwanted body from cornea or conjunctiva	313	27.9	851	75.9
Removal of unwanted body from air passages	311	27.9	961	86.2
Removal of ingrown nail	310	27.8	954	85.6
Treatment of subungual bruise	262	23.7	832	75.4
Cauterisation of nosebleed	219	19.9	694	63.0
Insertion of nasogastric tube / gastric lavage	224	19.6	1,010	88.3
Removal of molluscum contagiosum	202	18.3	743	67.3
Electrocardiogram	177	15.5	943	82.7
Low risk normal birth	151	13.3	1,084	95.2
Removal of painful callus	126	11.5	657	59.9
Cryotherapy or chemical therapy for genital wart	121	11.0	686	62.4
Removal of cysts, lipoma, nevi	111	10.1	694	63.2
Acupuncture	84	7.5	528	46.9
Scraping for determination of fungi	58	5.3	573	52.2
High risk normal birth	46	4.1	609	54.1
Cryotherapy for skin lesions	42	3.8	468	42.4

Characteristic		Number of procedures, activities and health actions executed			Number of procedures, activities and health actions that doctor knows how to execute
Characteristic		Average ± SD	Median	p-value^* * Calculated by Mann Whitney test.	Average ± SD	Median	p-value^* * Calculated by Mann Whitney test.
Gender
	Female	22.0 ± 7.5	21.0	0.001	38.4 ± 9.3	41.0	<0.001
	Male	23.8 ± 8.8	22.0		40.6 ± 8.5	43.0
Age^§ § Data dichotomized by the median. REF = Reference group. , years
	≤ 43	23.0 ± 7.8	22.0	0.139	39.6 ± 8.4	42.0	0.495
	> 43 years	22.7 ± 8.5	21.0		39.3 ± 9.5	42.0
Nationality
	Brazilian	22.4 ± 8.1	21.0	REF	37.3 ± 8	39.0	REF
	Cuban	22.9 ± 8.2	21.0	0.800	40 ± 9.3	43.0	<0.001
	Other	22.9 ± 7.9	22.0	0.768	39.4 ± 7.9	41.0	0.005
Country of training
	Brazil	21.7 ± 8.5	20.0	0.061	35.9 ± 8.8	38.0	<0.001
	Outside Brazil	23.0 ± 8.1	21.0		40 ± 8.9	43.0
Years since graduation
	≤ 17	23.5 ± 8.0	22.0	0.005	39.8 ± 8.1	42.0	0.498
	> 17 years	22.4 ± 8.3	20.0		39.3 ± 9.6	42.5
Specialist qualification?
	Yes	22.9 ± 8.4	21.0	0.625	39.6 ± 9.3	43.0	<0.001
	No	22.2 ± 7.4	21.0		37.8 ± 7.8	39.0
Time working in primary care^§ § Data dichotomized by the median. REF = Reference group.
	≤ 8 years	22.5 ± 8.3	21.0	0.349	38.2 ± 9.6	41.0	<0.001
	> 8 years	23.0 ± 8.2	21.0		40.3 ± 8.6	43.0
Time in this primary health unit
	≤ 2 years	22.3 ± 7.9	21.0	0.026	39.3 ± 9	42.0	0.165
	> 2 years	23.5 ± 8.6	22.0		39.6 ± 9.2	42.0
Location of unit: Region
	North	24.6 ± 8.1	24.0	<0.001	42.4 ± 6.6	44.0	<0.001
	Northeast	22 ± 8.3	20.0	REF	39.5 ± 9.1	42.0	REF
	Southeast	22.3 ± 8.4	20.0	0.666	37.8 ± 9.9	41.0	0.005
	South	24.6 ± 7.8	24.0	<0.001	39.3 ± 8.9	42.0	0.632
	Center-West	22.6 ± 7.2	21.0	0.196	39.6 ± 8.7	41.0	0.728
Scale of municipality
	State capital or metropolitan region	20.7 ± 8.0	19.0	REF	37.6 ± 9.8	40.0	REF
	Population: Over 100,000	21.0 ± 7.1	20.0	0.440	37.6 ± 9.3	40.0	0.835
	Population: 50,000 – 100,000	21.0 ± 6.4	20.0	0.452	39.5 ± 7.3	40.0	0.256
	Population: 20,000 – 50,000	23.0 ± 8.3	21.0	0.002	39.6 ± 9.4	42.5	0.001
	Population: 10,000 – 20,000	25.2 ± 8.7	25.0	<0.001	40.8 ± 9.0	44.0	<0.001
	Population: up to 10,000	26.6 ± 8.3	27.5	<0.001	42 ± 7.6	44.0	<0.001
Journey time to health region HQ
	Up to 15 minutes	21.2 ± 7.6	20.0	REF	38.5 ± 9.0	41.0	REF
	16–30 minutes	22.5 ± 8.6	20.0	0.090	38.1 ± 10.5	41.0	0.551
	31–45 minutes	22.6 ± 8.2	21.0	0.154	39.3 ± 8.7	41.0	0.187
	45–60 minutes	23.1 ± 7.9	22.5	0.012	39.4 ± 9.9	43.0	0.023
	61–120 minutes	24.3 ± 8.8	23.0	<0.001	40 ± 9.0	43.0	0.001
	Over 120 minutes	26.1 ± 7.8	25.0	<0.001	43 ± 7.0	45.0	<0.001

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[1] Collaborations

SN Girardi, CL Carvalho and CR Pierantoni worked on the conception of the project, significant critical review of the content of the paper, and final approval of the version to be published; JO Costa, ACS Stralen, TV Lauar and RB David worked in the collection, treatment, analysis and interpretation of the data, and writing of the paper.