The importance of a database in the management of healthcare services

Study carried out at: Oncology and Hematology Center, Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil. 1 Care Practice Service, Oncology and Hematology, Sociedade Beneficente Israelita Brasileira Hospital Albert Einstein – SBIBHAE, São Paulo (SP), Brazil. 2 Hospital Cancer Registry, Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil. 3 Hospital Cancer Registry of the State of São Paulo, Fundação Oncocentro de São Paulo – FOSP, São Paulo (SP), Brazil.

In Brazil, estimates for the years 2010 and 2011 near 489270 new cancer cases, the most frequent of which in The importance of a database in the management einstein.2012;10(3):360-5 the prostate and lung for males, and in the breast and uterine cervix for females (1) .
Thus, investment in and development of measures to improve cancer control by means of early detection, surveillance of risk factors and research have become fundamental.Based on reliable records and data, it is possible to carry out analyses that are the foundation for decision-making as to management and care (2,3) .
In order to establish and implement specific measures, the existence of Hospital Cancer Registries (HCR, acronym in Portuguese) and Population-Based Cancer Registries (PBCR) is essential, as they are responsible for reporting updated quality information on cancer and represent the population.These registries are considered by the National Institute of Cancer (INCA) as "powerful tools for the epidemiological surveillance of cancer in the country" (4) .
To accompany and analyze information on cancer, in the state of São Paulo there is the Fundação Oncocentro de São Paulo (FOSP), a public institution connected to the State Health Secretariat, which assists the preparation and implementation of healthcare policies in the field of Oncology in the State, and serves as an instrument so that oncology hospitals can prepare their own protocols and improve their care practices (5) .
The primary objectives of FOSP are to record new cases of cancer and the follow-up of patients, in order to accompany the progression of the disease and carry out epidemiological studies in this area (6) .
For this, FOSP utilizes a software called Hospital Cancer Registry System (SisHCR), which is made available to the 75 High-Complexity Oncology Centers and 5 volunteer hospitals, which forward their information to this organization (5,6) .
The hospitals that collaborate with FOSP have a sector denominated HCR, which is responsible for transmitting information on cancer to FOSP and to the organization of which they are a part (7) .
By means of the HCR data, it is possible to identify the care offered to the oncology patient and therefore, to improve care given to this population.In addition, these data can be used as sources of information for administrative planning, clinical research, and to provide an efficient control of the follow-up of patients treated, allowing the analysis of their survival.
Another contribution is that the HCR enables exchanging information with other hospital registries, as well as the organization of collaborative studies that may more widely characterize a type of cancer in a given population.
In light of this, the HCR becomes an important instrument for epidemiological studies, besides being a resource that allows analysis of the efficiency and efficacy of diagnostic and therapeutic procedures in cancer, along with the evaluation of outcomes such as survival and relapses.

oBJectiVe
The objectives of this study were to present the epidemiological profile of patients with cancer belonging to the HCR database of an Oncology and Hematology Center, and to report the importance of such a database for the management of healthcare services in this type of organization.

metHods type of study
Level I retrospective descriptive exploratory study, with quantitative data analysis.Quantitative, descriptive and exploratory research is that in which detailed descriptions of existing variables are collected, and data are used to justify and evaluate practical conditions of care (8,9) .

setting
The study was developed at the Oncology and Hematology Center of a large general hospital located in the City of São Paulo.

Population and sample
The population was made up of patients with cancer of the colon and rectum, breast, prostate and lung.The period analyzed was between the years 2004 and 2009.
Patients presented at the institution with the following status: (1)

instrument for data collection
For data collection, the researchers used the SisHCR software, and for data analysis, Excel ® .
For safety and reliability of the databank, passwords were created to access the files in order to guarantee the use of the data only by authorized researchers.Weekly backups were made of the spreadsheets, and the files were stored in a restricted access network.
To determine the spread degree of the tumors, the researchers utilized the TNM system.This system, developed by the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC), determines staging of solid tumors by measuring the size of the tumor (T), verifying if the disease affected any lymph node (N) and if there is distant metastasis (M) (10) .

implementation of data collection
Data collection was carried out between February 1 st , 2012 and March 24 th , 2011, after approval of the project by the Research Ethics Committee (CEP) of the Hospital Israelita Albert Einstein (HIAE), under number 1497.As this was a non-interventional retrospective project conducted in patient files and with mandatory confidentiality, we requested from CEP authorization to not use the Informed Consent Form (ICF).
The authors committed to using the information obtained exclusively in this research project, and to maintaining strictly confidential the identification of subjects, as per Resolution 96/1996.

analysis and presentation of the results
The data were presented in absolute numbers and percentages, in the form of tables and graphs.
In constructing the HCR database, we used the patient's CPF number [Individual Taxpayer Register] and the medical chart number, thus avoiding duplicity in data.

ResUlts incidence
We analyzed a sample of 1617 patient medical files.Of this total, 191 (11.81%) belonged to the lung group, 327 (20.22%) to the colon and rectum group, 510 (31.53%) were of the prostate group, and 589 (36.42%) were of the breast group, as presented on table 1.
Breast cancer had the highest incidence, represented almost 40% of the total sample.The second most frequently observed disease was prostate cancer, with 32%.

gender
In the female gender, breast cancer stands out as the most frequent disease, and for the male gender, prostate cancer had the highest incidence, as demonstrated on table 2. For both colon and rectum cancer and for lung cancer, the greatest incidence was shown in males, with 53.52% and 60.73%, respectively.

age group
Table 3 shows the number of patients distributed by age groups.A high incidence of colon and rectal cancer is noted for ages 70 years or older, with 130 patients, which represents almost 40% of the 327 patients with this disease.The survival curve shown in figure 2 demonstrates the importance of the relation between the early recognition of the disease and its outcome.It shows that the longer the time until diagnosis, the shorter the survival time the patient might have (11) .

discUssion
In healthcare, the use of a system to support decisionmaking regarding management and care may be greatly helpful, as it allows analysis of data by cross-referencing information, relating health problems with their determining factors and identifying the risks for disease involvement (12) .Such indicators will serve as elements for implementation of measures in prevention, improving the quality of life of patients (11) .
As already observed in other health-related studies, the use of information systems has become fundamental to accompany and offer answers to the new and complex demands resulting from organizational transformations.
A study carried out in the city of Ribeirao Preto (SP) aimed to develop a system to support decisionmaking as to nursing diagnoses and interventions in victims of trauma in advanced pre-hospital care (13) .The results of this study indicated that the correctly stored information and the follow-up time were ideal to search for diagnosis and interventions.It was concluded that implementation of the system optimized the time spent in drawing up the nursing diagnosis of patients victims of trauma (13) .
For example, by means of analysis of the information extracted from the HCR database, the high incidence of colon and rectum cancer in the age group 70 years or older was identified, which can be explained by the fact that this cancer has a slow and silent development.The diagnosis is habitually made at older ages, and consequently, at a later stage of disease, significantly worsening the patient's prognosis (14) .
Moreover, stage II had the highest incidence among the patients analyzed.Stage I cancers are the least advanced, and generally have a better prognosis; those of stages III and IV are more advanced, but in many cases they can also be successfully treated (10) .The treatment is more efficient in cancer patients at advanced stage of the disease.The cost of metastatic tumor treatment is approximately double that for patients diagnosed with local disease (15) .
For management and care in a service or hospital specialized in oncology, it is extremely important to know the epidemiological profile of its population.Within this context, owning a reliable database is an enormous help in decision-making, for example, about the types of treatments that will be offered and the establishment of campaigns for early detection of cancer, besides serving as a basis for planning its physical structure.
In order to transmit more precise data, the HCR of the HIAE performs dynamic data collection, with information coming from six different sources, as shown in figure 4.After preparing the general spreadsheet, the data were analyzed and tabulated by the FOSP SisRHC software, and based on that, it was possible to carry out studies on the different types of cancers.
The information generated by the HCR is transmitted periodically to the steering committee of the Oncology and Hematology Center of the organization, to inform and support continuous improvement of the management and care processes of this healthcare segment.
The improvement implemented by means of the information extracted from the HCR justifies the importance of the existence of a database that helps in management of the healthcare services in a Oncology and Hematology Center.For these reasons and as a complement to this study, a second study will be developed, seeking to strengthen the importance of this managerial tool and to describe the improvements of the processes implemented in the HCR of the HIAE.

conclUsion
The present study suggested that the information of the HCR database plays a relevant role for the various oncological services and hospitals, since it is able to generate a pool of important data related to cancer.
By means of this information, it is possible to carry out epidemiological studies and use them as resources that allow an analysis, for example, of the quality of care given to oncology patients, which consequently, may generate improvement measures in the care offered to this population.Additionally, with the use of the results obtained with this database, it is possible to obtain information capable of helping in administrative planning, and therefore, to improve the management of healthcare services of the institution.
Therefore, it was concluded that an oncology database is extremely important for the processes of management and care, as long as its information is collected, tabulated, stored and monitored with safety.

Figure 1 .
Figure 1.Staging of the four types of tumor analyzed in the sample, according to clinical stage.Stage 0: in situ; stage Y: tumors not classified according to TNM

Figure 2 .
Figure 2. Kaplan Survival Curve -Breast 2009.Survival (%) of cases of breast tumors according to clinical staging and time in months

Figure 3 .
Figure 3. Types of treatment used in fighting cancer of the breast, prostate, colon and rectum, and lung

Figure 4 .
Figure 4. Demonstration of flow of capture of oncology patients for the Hospital Cancer Registries

table 1 .
Distribution of the number of patients, according to topography, between the years 2004 and 2009

table 2 .
Distribution of male and female genders within the four topographies

table 3 .
Number of patients with cancer of the breast, prostate, colon and rectum, and lung, by age group stagingAccording to figure1, stage II showed the highest incidence, with a total of 44% of the sample.Stage II had 24.7%, III had 15%, IV had 10%, in situ had 5.8%, and Y represented 0.5% of the cases analyzed.The importance of a database in the management einstein.2012;10(3):360-5