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BACKGROUND: Ambulatory Health Care Networks (Amb-HCN) are circuits of patient referral and counter-referral that emerge, explicitly or spontaneously, between doctors who provide care in their offices. Finding a meaningful analytical representation for the organic and hierarchical functioning of an Amb-HCN may have managerial and health policymaking implications. We aimed to characterize the structural and functional topology of an Amb-HCN of a private health insurance provider (PHIP) using objective metrics from graph theory. METHODS: This is a cross-sectional quantitative study with a secondary data analysis study design. A Social Network Analysis (SNA) was conducted using office visits performed between April 1, 2021 and May 15, 2022, retrieved from secondary administrative claim databases from a PHIP in Belo Horizonte, Southeastern Brazil. Included were beneficiaries of a healthcare plan not restricting the location or physician caring for the patient. A directional and weighted network was constructed, where doctors were the vertices and patient referrals between doctors, within 7-45 days, were the network edges. Vertex-level SNA measures were calculated and grouped into three theoretical constructs: patient follow-up (aimed at assessing the doctor's pattern of patient follow-up); relationship with authorities (which assessed whether the doctor is an authority or contributes to his or her colleague's authority status); and centrality (aimed at positioning the doctor relative to the network graph). To characterize physician profiles within each dimension based on SNA metrics results, a K-means cluster analysis was conducted. The resulting physician clusters were assigned labels that sought to be representative of the observed values of the vertex metrics within the clusters. FINDINGS: Overall, 666,263 individuals performed 3,863,222 office visits with 4,554 physicians. A total of 577 physicians (12.7%) had very low consultation productivity and contributed very little to the network (i.e., about 1.1% of all referrals made or received), being excluded from subsequent doctor profiles analysis. Cluster analysis found 951 (23.9%) doctors to be central in the graph and 1,258 (31.6%) to be peripheral; 883 (22.2%) to be authorities and 266 (6.7%) as seeking authorities; 3,684 (92.6%) mostly shared patients with colleagues, with patient follow-up intensities ranging from weak to strong. Wide profile dispersion was observed among specialties and, more interestingly, within specialties. Non-primary-care medical specialties (e.g., cardiology, endocrinology etc.) were associated with central profile in the graph, while surgical specialties predominated in the periphery, along with pediatrics. Only pediatrics was associated with strong and prevalent (i.e., low patient sharing pattern) follow-up. Many doctors from internal medicine and family medicine had unexpectedly weak and shared patient follow-up profiles. Doctor profiles exhibited pairwise relationships with each other and with the number of chronic comorbidities of the patients they treated. For example, physicians identified as authorities were frequently central and treated patients with more comorbidities. Ten medical communities were identified with clear territorial and specialty segregation. CONCLUSIONS: Viewing the Amb-HCN as a social network provided a topological and functional representation with potentially meaningful and actionable emerging insights into the most influential actors and specialties, functional hierarchies, factors that lead to self-constituted medical communities, and dispersion from expected patterns within medical specialties.
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Medicina , Médicos , Humanos , Masculino , Feminino , Criança , Estudos Transversais , Análise de Rede Social , Encaminhamento e ConsultaRESUMO
Aim: The COVID-19 pandemic devastated healthcare around the world. Data about the COVID-19 outcomes among young people are still scarce. We aim to identify factors associated with the composite outcome among children and adolescents hospitalized due to COVID-19. Methods: We performed a search in the database of a large Brazilian private healthcare system. Insured people aged 21 years or younger who were hospitalized due to COVID-19 from Feb/28th/2020 to Nov/1st/2021 were included. The primary endpoint was the composite outcome consisting of ICU admission, need for invasive mechanical ventilation, or death. Results: We evaluated 199 patients who had an index hospitalization due to COVID-19. The median monthly rate of index hospitalization was 2.7 (interquartile range [IQR], 1.6-3.9) per 100,000 clients aged 21 years or less. The median age of the patients was 4.5 years (IQR, 1.4-14.1). At the index hospitalization, the composite outcome rate was 26.6%. The composite outcome was associated with all the previous coexisting morbidities evaluated. The median follow-up was 249.0 days (IQR, 152.0-438.5). There were 27 readmissions (16 patients) within 30 days after the discharge. Conclusions: In conclusion, hospitalized children and adolescents had a composite outcome rate of 26.6% at the index hospitalization. Having previous chronic morbidity was associated with the composite.
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Background: Darunavir has been proven efficacious for antiretroviral-experienced HIV-1-infected patients in randomized trials. However, effectiveness of darunavir-based salvage therapy is understudied in routine care in Brazil. Methods: Retrospective cohort study of HIV-1-infected patients from three public referral centers in Belo Horizonte, who received a darunavir-based therapy between 2008 and 2010, after virologic failure. Primary endpoint was the proportion of patients with viral load <50 copies/mL at week 48. Change in CD4 cell count was also evaluated. Outcome measures were analyzed on an intent-to-treat basis applied to observational studies. Sensitivity analysis was conducted to evaluate the impact of missing data at week 48. Predictors of virologic failure were examined using rare-event, finite sample, bias-corrected logistic regression. Results: Among 108 patients, the median age was 44.2 years, and 72.2% were male. They had long-standing HIV-1 infection (median 11.6 years) and advanced disease (76.9% had an AIDS-defining event). All patients had previously received protease inhibitors and nucleoside reverse transcriptase inhibitors, 75% nonnucleoside reverse transcriptase inhibitors, and 4.6% enfuvirtide. The median length of protease inhibitor use was 8.9 years, and 90.8% of patients had prior exposure to unboosted protease inhibitor. Genotypic resistance profile showed a median of three primary protease inhibitor mutations and 10.2% had three or more darunavir resistance-associated mutations. Virologic success at week 48 was achieved by 78.7% (95% CI = 69.7–86%) of patients and mean CD4 cell count increase from baseline was 131.5 cells/μL (95% CI = 103.4–159.6). In multiple logistic regression analysis, higher baseline viral load (RR = 1.04 per 10,000 copies/mL increase; 95% CI = 1.01–1.09) and higher number of darunavir resistance-associated mutations (RR = 1.23 per each; 95% CI = 0.95–1.48) ...
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Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Terapia de Salvação , Sulfonamidas/uso terapêutico , Brasil , Farmacorresistência Viral/genética , Genótipo , Infecções por HIV/imunologia , Infecções por HIV/virologia , HIV-1 , Estudos Retrospectivos , Carga ViralRESUMO
BACKGROUND: Darunavir has been proven efficacious for antiretroviral-experienced HIV-1-infected patients in randomized trials. However, effectiveness of darunavir-based salvage therapy is understudied in routine care in Brazil. METHODS: Retrospective cohort study of HIV-1-infected patients from three public referral centers in Belo Horizonte, who received a darunavir-based therapy between 2008 and 2010, after virologic failure. Primary endpoint was the proportion of patients with viral load<50 copies/mL at week 48. Change in CD4 cell count was also evaluated. Outcome measures were analyzed on an intent-to-treat basis applied to observational studies. Sensitivity analysis was conducted to evaluate the impact of missing data at week 48. Predictors of virologic failure were examined using rare-event, finite sample, bias-corrected logistic regression. RESULTS: Among 108 patients, the median age was 44.2 years, and 72.2% were male. They had long-standing HIV-1 infection (median 11.6 years) and advanced disease (76.9% had an AIDS-defining event). All patients had previously received protease inhibitors and nucleoside reverse transcriptase inhibitors, 75% nonnucleoside reverse transcriptase inhibitors, and 4.6% enfuvirtide. The median length of protease inhibitor use was 8.9 years, and 90.8% of patients had prior exposure to unboosted protease inhibitor. Genotypic resistance profile showed a median of three primary protease inhibitor mutations and 10.2% had three or more darunavir resistance-associated mutations. Virologic success at week 48 was achieved by 78.7% (95% CI=69.7-86%) of patients and mean CD4 cell count increase from baseline was 131.5 cells/µL (95% CI=103.4-159.6). In multiple logistic regression analysis, higher baseline viral load (RR=1.04 per 10,000 copies/mL increase; 95% CI=1.01-1.09) and higher number of darunavir resistance-associated mutations (RR=1.23 per each; 95% CI=0.95-1.48) were independently associated with virologic failure. CONCLUSION: Virologic suppression is a realistic endpoint for most treatment-experienced patients who begin a darunavir-based therapy outside the controlled conditions of a randomized trial, at routine care settings.
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Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Terapia de Salvação , Sulfonamidas/uso terapêutico , Adulto , Brasil , Contagem de Linfócito CD4 , Darunavir , Farmacorresistência Viral/genética , Feminino , Genótipo , Infecções por HIV/imunologia , Infecções por HIV/virologia , HIV-1/genética , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Carga ViralRESUMO
The effectiveness of switching from enfuvirtide to raltegravir in HIV-1-infected patients on a suppressive antiretroviral regimen has been poorly studied in the clinical practice of developing countries. We conducted a multicenter retrospective cohort study in HIV-1-infected, multidrug-experienced adults (≥18 years old) with plasma HIV-1-RNA <400 copies/ml for at least 4 months on an enfuvirtide-containing therapy between 2005 and 2010, in whom the attending physician switched from enfuvirtide to raltegravir. Effectiveness endpoints were measured at week 48 after switch. Analyses were conducted on an intent-to-treat basis and two strategies for handling missing outcome data were used (hereafter, strategies 1 and 2). Overall, 87 patients were eligible for analysis. At baseline, the median CD4(+) T cell count was 400 cells/µl and 91.9% of patients had <50 HIV-1-RNA copies/ml. At week 48, the proportions of patients with plasma HIV-1-RNA <50 and <400 copies/ml were, respectively, 86.2% (95% CI=77.1; 92.7%) and 88.5% (95% CI=79.9; 94.3%) (strategies 1 and 2) and 89.7% (95% CI=81.3; 95.2%) and 90.8% (95% CI=82.7; 95.9%) (strategies 1 and 2). This was a -10.3% (95% CI=-2.8; -17.9%) and -9.2% (95% CI=-2; -16.4%) difference from baseline in the proportion of patients with plasma HIV-1-RNA <400 copies/ml. The median increase in CD4(+) T cell counts was 41 and 64 cells/µl (p<0.001) (strategies 1 and 2). No patient withdrew raltegravir or developed opportunistic infections, but one was diagnosed with HIV-related dementia. In conclusion, switching from enfuvirtide to raltegravir in patients on a virologically suppressive regimen is an effective strategy even in a Brazilian clinical setting.
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Fármacos Anti-HIV/uso terapêutico , Farmacorresistência Viral , Proteína gp41 do Envelope de HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/virologia , HIV-1/efeitos dos fármacos , Fragmentos de Peptídeos/uso terapêutico , Pirrolidinonas/uso terapêutico , Adolescente , Adulto , Brasil , Contagem de Linfócito CD4 , Estudos de Coortes , Enfuvirtida , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , RNA Viral/sangue , Raltegravir Potássico , Resultado do Tratamento , Carga Viral , Adulto JovemRESUMO
INTRODUCTION: Published data addressing the effectiveness of darunavir-ritonavir (DRV/r)-based therapy for multiexperienced patients in developing countries are scarce. This study evaluated the 48-week virologic and immunologic effectiveness of salvage therapy based on DRV/r for the treatment of multidrug-experienced HIV-1-infected adults in Brazil. MATERIALS AND METHODS: A multicenter retrospective cohort study was carried out with multidrug-experienced adults who were on a failing antiretroviral therapy and started a DRV/r-based salvage therapy between 2008 and 2010. The primary effectiveness end point was the proportion of patients with virologic success (plasma HIV-1 RNA <50 copies/mL at week 48). RESULTS: At 48 weeks, 73% of the patients had HIV-RNA <50 copies/mL and a mean increase of 108 CD4 cells/mm(3). Higher baseline viral load, lower baseline CD4 count, younger age, and 3 or more DRV/r-associated resistance mutations were significantly predictive of virologic failure. Concomitant use of raltegravir was strongly associated with virologic success. CONCLUSION: The use of DRV/r-based regimens for salvage therapy is an effective strategy in the clinical care setting of a developing country.
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Infecções por HIV/tratamento farmacológico , Inibidores da Protease de HIV/uso terapêutico , HIV-1/efeitos dos fármacos , Ritonavir/uso terapêutico , Sulfonamidas/uso terapêutico , Adulto , Brasil , Contagem de Linfócito CD4 , Estudos de Coortes , Darunavir , Farmacorresistência Viral , Feminino , Infecções por HIV/imunologia , Infecções por HIV/virologia , HIV-1/genética , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Carga ViralRESUMO
A retrospective cohort study was performed to assess the impact of a Case Management Home Care Program supplied by the Unimed-BH medical cooperative on hospitalization-free survival time among eligible patients 60 years or older. A Cox proportional hazards model was fitted to assess the impact of home visits by health professionals on hospitalization-free survival time in a sample of 2,943 elders, while adjusting for patient age, physical dependence, medicines, feeding route, pressure ulcers, supplemental oxygen therapy, cognitive impairment, outpatient visits, and hospitalizations in the preceding quarter. Risk factors for shorter hospitalization-free survival time were: degree of physical dependence, enteral nutrition, supplemental oxygen therapy, pressure ulcers, and hospital admissions in the previous quarter. Higher rates of home visits by physicians and nurses showed a protective dose-response effect on hospitalization-free survival time. The data suggest that regular home visits by physicians and nurses lengthen hospitalization-free survival time among elderly patients enrolled in the program.
Foi realizado estudo de coorte retrospectiva com o objetivo de avaliar o impacto do plano de cuidados do Programa de Atenção Domiciliar da Unimed-BH, modalidade Gerenciamento de Casos (PrGC/AD), sobre o tempo livre de hospitalização entre os pacientes com 60 anos ou mais assistidos pelo programa. Utilizou-se o modelo de Cox para avaliar o efeito do intervalo entre as visitas domiciliares dos profissionais do programa sobre o tempo livre de hospitalização de 2.943 idosos, ajustado por idade, medicamentos em uso, via de alimentação, úlcera de pressão, déficit cognitivo, dependência física, oxigenioterapia, consultas ambulatoriais e hospitalizações no trimestre anterior. Foram fatores de risco para menor tempo livre de hospitalização: o grau de dependência física, alimentação enteral, oxigenioterapia suplementar, úlceras de pressão e hospitalizações no trimestre anterior. Observouse efeito protetor dose-resposta da frequência de visitas médicas e de enfermagem. Os resultados sugerem que visitas domiciliares regulares de médico e enfermeiro aumentam significativamente o tempo livre de hospitalização nos pacientes assistidos pelo PrGC/AD.
Se realizó un estudio de cohorte retrospectivo para evaluar el impacto de un plan de asistencia del Programa de Atención Domiciliaria de Unimed-BH, modalidad de Gestión de Casos (PrGC/AD), sobre el tiempo libre de hospitalización en pacientes con 60 años o más. Se usó el modelo de riesgos proporcionales de Cox para evaluar el efecto del intervalo entre las visitas domiciliarias de los profesionales del programa sobre el tiempo libre de hospitalización de 2.943 ancianos, ajustado por edad, medicamentos usados, vía de alimentación, úlcera por presión, deterioro cognitivo, dependencia física, oxigenoterapia, consultas ambulatorias y hospitalizaciones en el trimestre anterior. Fueron factores de riesgo para un menor tiempo libre de hospitalización: grado de dependencia física, alimentación enteral, oxigenoterapia suplementaria, úlcera por presión y hospitalizaciones en el trimestre anterior. Las frecuencias de visitas médicas y de enfermeros tuvieron un efecto protector dosis-respuesta. Los resultados sugieren que las visitas domiciliarias regulares de médico y enfermero aumentan el tiempo libre de hospitalización en los pacientes asistidos por el PrGC/AD.
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Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistemas Pré-Pagos de Saúde/normas , Serviços de Saúde para Idosos/normas , Serviços de Assistência Domiciliar/normas , Hospitalização/estatística & dados numéricos , Brasil , Estudos de Coortes , Serviços de Assistência Domiciliar/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Fatores de TempoRESUMO
A retrospective cohort study was performed to assess the impact of a Case Management Home Care Program supplied by the Unimed-BH medical cooperative on hospitalization-free survival time among eligible patients 60 years or older. A Cox proportional hazards model was fitted to assess the impact of home visits by health professionals on hospitalization-free survival time in a sample of 2,943 elders, while adjusting for patient age, physical dependence, medicines, feeding route, pressure ulcers, supplemental oxygen therapy, cognitive impairment, outpatient visits, and hospitalizations in the preceding quarter. Risk factors for shorter hospitalization-free survival time were: degree of physical dependence, enteral nutrition, supplemental oxygen therapy, pressure ulcers, and hospital admissions in the previous quarter. Higher rates of home visits by physicians and nurses showed a protective dose-response effect on hospitalization-free survival time. The data suggest that regular home visits by physicians and nurses lengthen hospitalization-free survival time among elderly patients enrolled in the program.
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Sistemas Pré-Pagos de Saúde/normas , Serviços de Saúde para Idosos/normas , Serviços de Assistência Domiciliar/normas , Hospitalização/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Brasil , Estudos de Coortes , Feminino , Serviços de Assistência Domiciliar/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Fatores de TempoRESUMO
INTRODUCTION: In Brazil there is a large area of overlap of visceral leishmaniasis (VL) and HIV infection, which favored a increased incidence of coinfection Leishmania/HIV. METHODS: This study evaluated 65 consecutive patients with VL and their clinical response to treatment in two health care settings in Belo Horizonte, Brazil. RESULTS: At baseline, the clinical picture was similar between both groups, although diarrhea and peripheral lymphadenomegaly were more frequent in HIV-infected subjects. HIV-positive patients had lower median blood lymphocyte counts (686/mm³ versus 948/mm³p = 0.004) and lower values of alanine aminotransferase (ALT) (48IU/L versus 75.6IU/L p = 0.016) than HIV-negative patients. HIV-positive status (hazard ratio = 0.423, p = 0.023) and anemia (HR = 0.205, p = 0.002) were independent negative predictors of complete clinical response following antileishmanial treatment initiation. CONCLUSIONS: This study reinforces that all patients with VL should be tested for HIV infection, regardless of their clinical picture. This practice would allow early recognition of coinfection with initiation of antiretroviral therapy and, possibly, reduction in treatment failure.
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Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Antiprotozoários/uso terapêutico , Coinfecção/tratamento farmacológico , Leishmaniose Visceral/tratamento farmacológico , Adulto , Fármacos Anti-HIV/uso terapêutico , Estudos de Coortes , Infecções por HIV/diagnóstico , Humanos , Masculino , Estudos RetrospectivosRESUMO
INTRODUCTION: In Brazil there is a large area of overlap of visceral leishmaniasis (VL) and HIV infection, which favored a increased incidence of coinfection Leishmania/HIV. METHODS: This study evaluated 65 consecutive patients with VL and their clinical response to treatment in two health care settings in Belo Horizonte, Brazil. RESULTS: At baseline, the clinical picture was similar between both groups, although diarrhea and peripheral lymphadenomegaly were more frequent in HIV-infected subjects. HIV-positive patients had lower median blood lymphocyte counts (686/mm³ versus 948/mm³p = 0.004) and lower values of alanine aminotransferase (ALT) (48IU/L versus 75.6IU/L p = 0.016) than HIV-negative patients. HIV-positive status (hazard ratio = 0.423, p = 0.023) and anemia (HR = 0.205, p = 0.002) were independent negative predictors of complete clinical response following antileishmanial treatment initiation. CONCLUSIONS: This study reinforces that all patients with VL should be tested for HIV infection, regardless of their clinical picture. This practice would allow early recognition of coinfection with initiation of antiretroviral therapy and, possibly, reduction in treatment failure.
INTRODUÇÃO: No Brasil, há uma grande área de sobreposição de leishmaniose visceral (LV) e infecção pelo HIV, o que favoreceu o aumento da incidência de co-infecção Leishmania/HIV. MÉTODOS: Este estudo avaliou a resposta clínica ao tratamento de 65 pacientes em dois centros de referência de saúde em Belo Horizonte, Brasil. RESULTADOS: O quadro clínico inicial foi semelhante entre os dois grupos, exceto pela maior frequência de diarréia e linfadenomegalia periférica em indivíduos infectados pelo HIV. Pacientes HIV-positivos apresentaram menor contagem de linfócitos no sangue (686/mm³versus 948/mm³p = 0,004) e menores valores de alanina aminotransferase (ALT) (48UI/L versus75,6UI/Lp = 0,016) do que pacientes HIV-negativos. Infecção pelo HIV-1 (hazard ratio-HR= 0,423, p = 0,023) e anemia (HR = 0,205, p = 0,002) foram preditores independentes de resposta clínica incompleta após o início do tratamento leishmanicida. CONCLUSÕES: Este estudo reforça a indicação de testagem para HIV em todos os pacientes diagnosticados com LV. O procedimento permitiria o reconhecimento precoce da co-infecção, levando à adequação do manejo clínico e o início da terapia antirretroviral, aumentando as chances de sucesso terapêutico.