Challenges and lessons from a primary care intervention in a Brazilian municipality

Andrade, Mônica V; Noronha, Kenya; Cardoso, Clareci S; Oliveira, Claudia D L; Calazans, Júlia A; Souza, Michelle N

doi:10.11606/S1518-8787.2019053000457

Mônica V Andrade

Universidade Federal de Minas Gerais. Departamento de Economia. Centro de Desenvolvimento e Planejamento Regional. Belo Horizonte, MG, Brasil

http://orcid.org/0000-0002-6821-1598

Kenya Noronha

Universidade Federal de Minas Gerais. Departamento de Economia. Centro de Desenvolvimento e Planejamento Regional. Belo Horizonte, MG, Brasil

http://orcid.org/0000-0002-7174-6710

Clareci S Cardoso

Universidade Federal de São João del-Rei. Campus Centro-Oeste. Departamento de Saúde Coletiva. Divinópolis, MG, Brasil

http://orcid.org/0000-0003-0689-1644

Claudia D L Oliveira

Universidade Federal de São João del-Rei. Campus Centro-Oeste. Departamento de Saúde Coletiva. Divinópolis, MG, Brasil

http://orcid.org/0000-0001-8533-8155

Júlia A Calazans

Universidade Federal de Minas Gerais. Departamento de Demografia. Centro de Desenvolvimento e Planejamento Regional. Belo Horizonte, MG, Brasil

http://orcid.org/0000-0002-6215-3251

Michelle N Souza

Universidade Federal de Minas Gerais. Departamento de Demografia. Centro de Desenvolvimento e Planejamento Regional. Belo Horizonte, MG, Brasil

http://orcid.org/0000-0002-1873-8316

Correspondence: Mônica V Andrade Centro de Desenvolvimento e Planejamento Regional (CEDEPLAR) Faculdade de Ciências Econômicas– UFMG Av. Antônio Carlos, 6627 Pampulha 31270-901 Belo Horizonte, MG, Brasil E-mail: mviegas123@gmail.com

Authors’ Contribution: Design and planning of the study: MVA, KN, CSC, CDLO. Data collection, analysis, and interpretation: MVA, KN, CSC, CDLO, JC, MNS. Preparation or review of the study: MVA, KN, CSC, CDLO, JC, MNS. Approval of the final version: MVA, KN, CSC, CDLO, JC, MNS. Public responsibility for the content of the article: MVA, KN.

Conflict of Interest: The authors declare no conflict of interest.

Steps	Main macroprocesses
1. Evaluation of the existing infrastructure and definition of improvements needed considering the reference population	Territorialization, registry of families, family risk classification, risk stratification of chronic conditions.
2. Primary care to acute health events	Patients’ reception at Health Unit, Manchester triage system, delivery of primary care according to Manchester protocol.
3. Primary care to patients with controlled chronic conditions	Management and monitoring of chronic conditions, risk stratification of chronic conditions, elaboration of patients care plan, self-care support.
4. Preventive care and tools to support behavior change	Physical activities, control of alcohol, tobacco and drugs, and nutritional re-education groups, motivational interviewing.
5. Administrative demands	Control of medical certificates, renewal of prescription of drugs and medicines, management of Health Units including information system, medical records and public health surveillance.
6. Home healthcare	Management and monitoring of household visits.
7. Self-care support	Self-care training and advice, elaboration of patients care plan, material support to self-care.

Variable	Definition	Data source
Health indicators related to macroprocesses
Familiar risk classification	Family risk classification considering social vulnerability, familiar and individual risk factors	Medical records
Risk stratification	Risk stratification of patients with diabetes or hypertension	Medical records
Registry of families	Enrolment status of the households by FHT	Household survey
CHA household visits	Household was visited by CHA at least once in the last 12 months	Household survey
SUS users	Individual usually receive care provided by SUS	Household survey
Private health insurance coverage	Individual has private health insurance coverage	Household survey
Diabetes	Individual self-reported having diabetes	Household survey
Hypertension	Individual self-reported having hypertension	Household survey
Health outcomes for Individuals with hypertension and diabetes
Doctor visit	Individual visited a doctor at least once in the last 12 months	Household survey
Doctor visit by SUS	Individual visited a doctor of SUS at least once in the last 12 months	Household survey
ECG test	Individual received at least one electrocardiogram test in the last 12 months	Household survey
Blood test or cholesterol test	Individual with diabetes did at least one blood test or Individual with hypertension did at one cholesterol test in the last 12 months	Household survey
Health outcomes associated with antenatal care (ANC), delivery, and child care
ANC provider	Main provider of ANC care: FHT, other professionals of SUS, private	Household survey
At least 6 ANC visits	Woman received at least 6 ANC visits during pregnancy	Household survey
Early prenatal care	Receiving care during the first three months of pregnancy	Household survey
Antenatal care tests	Tests performed during pregnancy: blood test, toxoplasmosis test, HIV and syphilis test, urine test, oral glucose test, ultrasound test	Household survey
Immunization	Woman was immunized against tetanus and influenza during pregnancy	Household survey
Preterm birth	Baby birth before 37 weeks of gestational age	Household survey
Vaginal delivery	Baby was born through vaginal delivery	Household survey
C-section scheduled	C-section scheduled during the ANC period	Household survey
Child immunization	Child immunization against BCG, hepatitis, poliomyelitis, DTP, rotavirus, meningitis, MMR	Household survey
Low birth weight	Birth weight below 2,500 kg	Household survey

Variable	Entire population						Diabetes						Hypertension

	2012		2014		χ² test (p-value)		2012		2014		χ² test (p-value)		2012		2014		χ² test (p-value)

	n	%	n	%			n	%	n	%			n	%	n	%
Household survey
Registry of families in FHS	558	95.88	575	93.65	0.085	NS	305	98.71	308	97.47	0.260	NS	350	97.77	364	96.55	0.324	NS
CHA household visits	532	90.94	588	94.99	0.006	^a	294	94.53	299	94.62	0.962	NS	327	90.08	359	94.97	0.011	^b
SUS patients	554	92.95	571	91.36	0.301	NS	310	99.36	309	97.78	0.927	NS	360	98.63	364	96.04	0.029	^b
Private health insurance	184	30.87	190	30.50	0.887	NS	107	34.41	108	34.07	0.929	NS	142	38.90	146	38.52	0.915	NS
Diabetes prevalence	27	4.53	59	9.44	0.001	^a
Hypertension prevalence	158	26.55	173	27.72	0.646	NS
Doctor visit							291	95.10	278	89.39	0.008	^a	303	85.11	305	81.12	0.150	NS
Doctor visit by SUS (conditional)							216	74.23	219	78.78	0.201	NS	207	68.54	199	65.25	0.3890	NS
ECG test							185	61.67	195	62.30	0.872	NS	174	48.07	173	45.77	0.531	NS
Blood test							276	92.00	270	89.40	0.273	NS
Cholesterol test													259	71.35	281	74.73	0.300	NS

Variable	Diabetes		Hypertension

	n	%	n	%
Family risk classification in the medical records of the patient
No	43	16.9	23	8.5
Yes	203	79.9	241	88.6
Does not know	8	3.2	8	2.9
Total	254	100	272	100
The most recent year of family risk classification
2009	9	4.4	10	4.2
2010	3	1.5	2	0.8
2011	0	0.0	2	0.8
2012	2	1.0	2	0.8
2013	87	42.9	68	28.2
2014	52	25.6	69	28.6
2015	6	3.0	19	7.9
No record of the year	44	21.7	69	28.6
Total	203	100	241	100
Individual risk stratification in the medical records of the patient
No	166	65.35	195	71.7
Yes	88	34.65	77	28.3
Total	254	100	272	100

Variable	2012		2014		χ² test (p-value)

	n	%	n	%
Antenatal care and delivery

ANC provider
FHT	130	72.63	114	75.00	0.132	NS
Other professionals of SUS	11	6.15	3	1.97
Private	38	21.23	35	23.03
At least 6 ANC visits, since she did the ANC	158	91.33	144	96.64	0.049	^b
Early prenatal care, since she did the ANC	156	85.16	144	94.12	0.008	^a
Antenatal care tests
Blood test	180	98.36	153	100.00	0.112	NS
Toxoplasmosis test	150	81.97	138	90.20	0.061	NS
Urine test	178	97.27	153	100.00	0.039	^b
HIV and syphilis test	167	91.26	146	95.42	0.284	NS
Oral glucose test	61	33.33	93	60.78	0.000	^a
Ultrasound test	182	99.45	153	100.00	0.360	NS
Immunization
Immunized against influenza	142	77.60	115	75.16	0.601	NS
Immunized against tetanus	166	90.71	140	91.50	0.765	NS
Preterm birth	48	26.23	42	27.45	0.527	NS
Vaginal delivery	39	21.31	31	20.26	0.813	NS
C-section scheduled, since the delivery was a c-section	94	65.28	62	50.82	0.017	^b
Low birth weight	21	11.67	17	10.97	0.841	NS

Child immunization according to the vaccination card

BCG	157	100.00	131	100.00
Hepatitis B (HepB)	158	99.37	130	99.24	0.891	NS
Oral polio vaccine (OPV)	158	100.00	121	100.00
DTP	159	100.00	120	99.17	0.278	NS
Rotavirus	157	99.37	120	100.00	0.372	NS
Pneumococcal	157	100.00	119	100.00
Meningococcal	159	100.00	119	100.00
MMR	129	98.47	23	100.00	0.244	NS
Yellow fever	137	100.00	27	100.00

[1] Correspondence: Mônica V Andrade Centro de Desenvolvimento e Planejamento Regional (CEDEPLAR) Faculdade de Ciências Econômicas– UFMG Av. Antônio Carlos, 6627 Pampulha 31270-901 Belo Horizonte, MG, Brasil E-mail: mviegas123@gmail.com

Brasil

Brasil

Challenges and lessons from a primary care intervention in a Brazilian municipality

ABSTRACT

OBJECTIVE

METHODS

RESULTS

CONCLUSIONS