A regulação ambulatorial na Atenção Primária do Município do Rio de Janeiro, Brasil, a partir dos médicos reguladores locais

Silva Junior, Cesar Luiz; Guabiraba, Kennedy Pereira de Lima; Gomes, Gustavo Graça; Andrade, Carla Lourenço Tavares de; Melo, Eduardo Alves

doi:10.1590/1413-81232022276.15702021

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Sumário

TEMAS LIVRES • Ciênc. saúde coletiva 27 (06) • Jun 2022 • https://doi.org/10.1590/1413-81232022276.15702021 copiar

A regulação ambulatorial na Atenção Primária do Município do Rio de Janeiro, Brasil, a partir dos médicos reguladores locais

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo

O artigo teve por objetivo caracterizar o processo de regulação assistencial realizado nas unidades de Atenção Primária à Saúde do município do Rio de Janeiro, com ênfase na dimensão ambulatorial. Foi realizado estudo transversal, por meio de um survey, com participação de 114 médicos reguladores locais, no ano de 2019. Quanto ao perfil dos reguladores locais, destacou-se o alto percentual com formação em Medicina de Família e Comunidade e o tempo de atuação relativamente adequado destes profissionais nas unidades. Para 52,6%, a infraestrutura para regulação é adequada, mas a conectividade apresenta problemas com frequência. No sistema de regulação, os mecanismos e horários de disponibilização de vagas produzem competição entre os reguladores das unidades, com sobrecarga de trabalho e iniquidades de acesso associadas. Observou-se importante envolvimento dos reguladores locais em atividades de avaliação e gestão de filas de espera. A maioria informou haver pouca ou nenhuma interação com a atenção especializada. Apesar do processo de regulação descentralizada ainda apresentar importantes limites, o estudo aponta a factibilidade e contribuição da entrada mais intensa da Atenção Primária na regulação do acesso.

Palavras-chave:
Assistência Integral à Saúde; Regulação em Saúde; Atenção Primária à Saúde

Variables		n	%
Gender
	Female	70	61.4
	Male	44	38.6
Age
	26-30 years of age	21	18.4
	31-35 years of age	30	26.3
	36-40 years of age	22	19.3
	Over 40 years of age	41	36.0
Education
	FCM Residency	58	50.9
	FCM Title	29	25.4
	Specialization in Family Health	16	14.0
	Collective Health Specialization or Residency	5	4.4
	Master's Degree	19	16.7
	PhD	4	3.5
	Others	23	20.2
Time since Graduation
	Less than 1 year	1	0.9
	Between 1-3 years	7	6.1
	Between 4-8 years	42	36.8
	Between 9-12 years	14	12.3
	More than 12 years	50	43.9
Type of Health Unit where you function as a regulator
	Family Clinic	71	62.3
	MHC with Family Health (mixed)	33	28.9
	Worked until 2019 in the unit, but is no longer working in any Basic or Primary Care Unit in the municipality	7	6.1
	Others (Polyclinics, SHC etc.)	3	2.6
Time working as a regulator in the Unit
	Less than 6 months ago	12	10.5
	Between 6 months and 1 year	10	8.8
	Between 1-2 years	27	23.7
	Between 3-4 years	26	22.8
	Between 5-6 years	17	14.9
	7 years or more	22	19.3
Role in local regulation
	Local regulator or physician with regulator access profile to SISREG	58	50.9
	Technical Officer (TO)	56	49.1

Categories	Variables		%
Characteristics of the unit and the programmatic area of operation	Location according to unit PHC
		PHC 1.0	12.3
		PHC 2.1	12.3
		PHC 2.2	4.4
		PHC3.1	21.9
		PHC 3.2	6.1
		PHC 3.3	11.4
		PHC 4.0	7.9
		PHC 5.1	2.6
		PHC 5.2	10.5
		PHC 5.3	10.5
	Number of family health teams per unit
		Between 1-3 teams	21.9
		Between 4-7 teams	60.5
	Average number of registered users per team
		Between 3001-4000 users/team	45.6
		More than 4000 users/team	40.4
	Easiest exams to perform in PHC (shorter waiting time)
		Radiography	63.2
		Mammography	42.1
		Ultrasonography	28.9
	Most difficult exams to perform in PHC (longer waiting time)
		MRI	27.2
		Colonoscopy	27.2
		Doppler	26.3
	Easiest specialties to perform in PHC (shorter waiting time)
		Dermatology	78.9
		Otolaryngology	39.5
		Pneumology	17.5
	Most difficult specialties to perform in PHC (longer waiting time)
		Ophthalmology	31.6
		Nephrology	29.8
		General Surgery	24.6
Technical preparation and structure for regulation	Preparation for regulation (MR)
		Peer-Driven	55.3
		Through courses and training on regulation	37.7
	IT and connectivity at the unit
		The infrastructure for regulation is adequate, but connectivity presents problems of instability and/or slowness frequently	52.6
	SISREG features and speed
		Features are adequate, but speed is unsatisfactory	62.3
	Clinical capacity and quality of requests from the unit's physicians
		Most physicians have good clinical training, and most requests are relevant	52.6
		It is very heterogeneous, depends very much on the physician and the type of examination/specialized consultation requested	36.0
Local activities and practices in the regulation process	Tools used in regulation (MR)
		SISREG	95.6
		Electronic Health Record	74.6
		Regulation Protocol	72.8
	Hours per week dedicated to local regulation
		Between 1-3 hours	31.6
		Between 4-8 hours	41.2
		More than 8 horas	20.1
	Place where regulation activities take place
		At work and outside of work	70.2
		Only when at work	29.8
	Type of actions performed in local regulation (MR)
		Requesting exams and consultations	97.4
		Analyzing requests	88.6
		Request for clarification or complementation (return or outstanding issues)	88.6
	Parameters applied to user scheduling
		Considers both the waiting time and the location of the performing unit	67.5
		Considers mainly the distance to the performing unit	21.1
		Seeks to schedule the consultation, procedure or exam considering mainly the waiting time	8.8
	Distance from the places to which users are referred
		The place of scheduling varies a lot, according to the specialty or exam, so it is not possible to say what happens in general	67.5
	Risk rating evaluation of the unit's requests
		They are very heterogeneous, varying according to the person requesting them and the unit's team	47.4
		They are almost always inserted with risk classification appropriate to the diagnostic hypothesis and the severity of the clinical condition of the described user	40.4
Interações do regulador local com outros profissionais da unidade e da Rede	Type of interaction between colleagues in the same unit (MR)
		In person on a daily basis	92.1
		By messaging application - WhatsApp	79.8
	Interaction with regulators from other units (MR)
		By messaging application - WhatsApp	82.5
		In person at meetings	41.2
	Interaction with other services in the network, beyond PHC
		There is little direct interaction with specialized services	63.2
		No direct interaction with specialized services	35.1
	Most frequent forms of direct interaction with specialists from other services
		By telephone	50.0
		By e-mail	45.9
	ECFH's participation in local regulation
		Participates	25.5
		Does not participate	48.2
		There is no ECFH in the unit	26.3
	Sector/level most sought after in case of problems/doubts beyond local governability
		IRC or RT of PAC	86.8
		Other RT colleagues	10.5

Category	Variables	Main Assessments by Regulators
Assessment of the decentralized regulation model	Main gains, benefits, or facilities of local regulation in PHC	Regulation done closer to the patients (n=42) - Better understanding of the main needs of the territory and the patients Local interaction and possibility of discussion among colleagues about regulation (n=42) - Better management of requests, queues, and vacancies - Improvements in the quality of referrals/solicitations and turning these moments into opportunities for case discussions Speed of regulation (n=41) - From the analysis of the requests to the scheduling of appointments: in some cases, the scheduling is immediate during the consultation, besides the regulation that can be made at any time
	Main difficulties, problems, or challenges of local regulation in PHC	Low offer/high waiting time (n=58) - Low supply of some specialties (with oversupply in some specialties and low supply for basic specialties such as general surgery) Imbalance between the time to regulate and the regulator time (n=41) - Time for vacancies to become available is “enemy” of time to regulate - Overload due to the accumulation of attributions Lack of information and other problems with referral flow (n=18) - Untimely availability of the profiles and inclusion criteria of each service, which are only visualized after the requests - Criticism to the functionalities of the regulation system - Connectivity problems and slowness of the regulation system
	Strategies or measures that could qualify the regulation	Qualification of the professionals (n=45) - Conducting capacity building/training at the levels of clinical skills, use of the regulation system, and regulation of certain queues - Qualification of requests, including risk classification Improvements in the availability and clarity of information regarding regulation (n=39) - Criteria for inclusion in services - Anticipation and updating of preparation information - Availability of qualified, practical, and direct guides and protocols Increasing supply (n=20) - Increasing the number of vacancies - Increasing the number of providers

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[1] Colaboradores

CL Silva Junior participou da análise de dados, redação, revisão e aprovação do manuscrito. KPL Guabiraba participou da análise de dados, redação e aprovação do manuscrito. GG Gomes participou da análise de dados, redação e aprovação do manuscrito. CLT Andrade participou da concepção, análise de dados, revisão e aprovação do manuscrito. EA Melo participou da concepção, análise de dados, redação, revisão e aprovação do manuscrito.