Avaliação do modelo de atenção primária para as doenças crônicas não transmissíveis no estado do Tocantins, 2012 e 2014

Abstract

Noncommunicable diseases are the leading cause of death worldwide as a result of diseases of the circulatory system, cancer, chronic respiratory diseases and diabetes, which are mainly caused by smoking, alcohol abuse, unhealthy eating, physical inactivity and overweight/ obesity. Two cross sectional studies were carried out using the database from the external evaluation cycles of the National Program for Improving Access and Quality of Primary Care, called PMAQ-AB, for the state of Tocantins. The first study evaluated the adequacy of the Family Health Strategy to the primary care model for chronic noncommunicable diseases and compared the changes that happened between the two cycles of PMAQ-AB external evaluations conducted in 2012 and 2014. It was used the information on the structure of the 233 Primary Health Units and on the work process of the 266 health teams. For the analysis, the Principal Component Analysis for Categorical Data technique, called CATPCA, and the McNemar chisquare statistics test were used for comparison of paired samples, at a significance level of 5% with a 95% Confidence Interval. The second study evaluated and compared the adequacy of the work process of family health teams in the Health Regions of the State of Tocantins to the Strategic Action Plan for tackling Noncommunicable Chronic Diseases. It was used information on the work process of 361 PMAQ family health teams from cycle 2 that occurred in 2014. It was also used the CATPCA analysis technique and Pearson's chi-square or Fisher's exact tests, the post hoc analysis for comparison of pairs, called pairwise comparations, at a significance level of 5% and Confidence Interval of 95%. The CATPCA for both studies was performed in the statistical program Statistical Package for the Social Sciences, version 24.0 as well as the chi-square test of McNemar. Pearson's or Fisher's chi-square tests followed by pairwise comparisons were performed on R software. The findings from the first study pointed to the low proportion of medicine dispensing for the treatment of chronic diseases. The availability of screening materials for cervical cancer was significantly reduced by approximately 5.0% in the first two cycles of PMAQ-AB. There was a significant increase in vaccination against seasonal influenza (from 49.8% to 84.5%) and the percentage of Primary Health Units with sterilization room (from 48.9% to 71.2%). More than 70.0% of the health teams started to carry out more health education activities (from 77.1% to 89.8%) and to xv encourage physical activity (from 51.1% to 70.3%), keep record of schoolchildren with health needs for follow-up (23.3% to 34.6%) and the evaluation of user satisfaction (from 28.2% to 53.8%). Actions for specific groups of hypertensive and diabetic patients were significantly reduced by approximately 3.0%. The analysis of the second study identified that the family health teams are acting in coherence with the strategic actions of the DCNT Tackling Plan, mainly with the health promotion axis, but with very unequal percentages among the Health Regions. Percentages of adequacy above 70% were observed for attention to specific groups of users (women, elderly, hypertensive and diabetic), as well as request for electrocardiogram and mammography exams and encouragement of physical activity. The lowest percentages of adequacy (up to 30.0%) for the active search for alcohol and drug dependent cases were observed, along with the use of protocols for risk stratification for COPD, record of users with COPD and obesity, identification of eligible women for mammography exam and electronic medical record. The analysis of pairwise comparations of the differences among the Health Regions identified higher percentages of adequacy in the Regions Bico do Papagaio (Region 1), Cantão (Region 4) and Capim Dourado (Region 5) compared to the Middle North Araguaia (Region 2) and Southeast (Region 8). Based on these two studies, the inadequacy of the Family Health Strategy to the primary care model directed at chronic diseases among the PMAQ-AB cycles assessed stands out, with notable deficiencies in the structure of the Primary Health Units and with the work process of family health teams very focused on specific groups. There was little focus on intersectoral actions, actions with the population of the assigned area or on the promotion of self-care supported for chronic diseases. The improvement of the current model of care requires the assurance of dispensing sufficient medicine for the treatment of chronic diseases, technological incorporation, electronic health records, expansion of tracking actions, use of protocols, interdisciplinary performance and matrix support, intersectoral actions, supported self-care and health promotion for the adequate tackling chronic diseases in Tocantins.