Avaliação do impacto do apoio matricial em nefrologia para as unidades de Atenção Primária à Saúde em Bauru no encaminhamento adequado e na diálise de início urgente: um estudo de intervenção de séries temporais
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Data
2023-04-10
Autores
Kojima, Christiane Akemi [UNESP]
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Universidade Estadual Paulista (Unesp)
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Introdução: No Brasil, a distribuição regional de médicos é desigual e há escassez de alguns especialistas. A nefrologia representa apenas 1,1% das especialidades médicas1 , e, além da escassez de especialistas, a patologia mais prevalente nos atendimentos nefrológicos, a doença renal crônica (DRC), tem tido um aumento crescente na taxa de incidência e prevalência. A importância do manejo adequado nos pacientes renais crônicos refletirá tanto no retardo da progressão da doença como na sobrevida dos pacientes nos estágios mais avançados. Neste cenário surge o apoio matricial pelo nefrologista aos médicos da atenção primária (AP) à saúde que consiste em novo modelo de produzir saúde, em um processo de construção compartilhada com proposta de intervenção pedagógico terapêutica, que aproxima médicos da AP ao especialista, através de encontros chamados Apoio matricial ou Matriciamento .Objetivo: Avaliar o impacto do apoio matricial em nefrologia quanto à adequação do encaminhamento para o especialista e no início urgente de terapia renal substitutiva nos pacientes incidentes dos hospitais de referência no município de Bauru. Objetivo secundário: avaliar o conhecimento em nefrologia dos médicos da AP antes e durante o matriciamento. Metodologia: Trata-se de um estudo de intervenção de séries temporais em relação à implantação do matriciamento em nefrologia, que foi realizado no ambulatório de especialidades médicas (AME), na cidade de Bauru, estado de São Paulo, com início em julho de 2019 a junho de 2020. Foram comparados a adequação dos encaminhamentos para a nefrologista no AME Bauru no período de um ano antes e após o matriciamento, considerados adequados aqueles que atendem os critérios baseados nos protocolos de encaminhamento ao nefrologista do Ministério da Saúde. Avaliados também as taxas e os dados sobre o perfil laboratorial e clínico de pacientes incidentes em terapia renal substitutiva (TRS) de início urgente nos centros de diálise dos hospitais de referência para pacientes do Sistema Único de Saúde (SUS), por meio de consulta em prontuários, pelo período de um ano antes e dois anos após o início do apoio matricial. O conhecimento 9 médico em nefrologia dos médicos da AP foi avaliado por meio de 15 questões sobre nefrologia aplicadas no primeiro e último encontro após o período de um ano. Resultados: Após a intervenção, o encaminhamento ao nefrologista de forma adequada se mostrou superior (51,56% vs 79,68%, p=0,002). Quanto às características dos pacientes encaminhados, observou-se perfil demográfico semelhante, sendo a alteração na função renal o principal motivo de encaminhamento ao nefrologista. Os grupos diferiram quanto ao diagnóstico inicial, sendo a DRC estágio III o principal no grupo de pacientes encaminhados anteriormente ao matriciamento e o estágio IV após o início do matriciamento. Após a intervenção, houve maior encaminhamento ao ambulatório de pré diálise (3,1% vs 17,2%, p=0,0019). Houve redução da prevalência dos pacientes que iniciaram TRS de início urgente no município de Bauru no período após a intervenção (86,42% vs 68,96%, p=<0,001). Não foram observadas diferenças significativas entre os pacientes que iniciaram a TRS quanto às características demográficas, clínicas ou laboratoriais. O conhecimento médico sobre temas em nefrologia diferiu entre os dois grupos de médicos avaliados no início e final do matriciamento. O grupo após o matriciamento teve maior número de erros de forma geral e nos temas DRC e hematúria, enquanto o grupo avaliado antes do matriciamento apresentou maior número de erros no tema litíase renal. Conclusão: Apesar da pandemia da COVID 19 ter prejudicado a realização do estudo, pode-se observar que o apoio matricial em nefrologia se mostrou eficaz quanto à melhora da adequação no encaminhamento ao nefrologista assim como impactou na redução da incidência de pacientes que iniciaram a diálise de modo urgente promovendo melhores condições de saúde com a assertividade dos encaminhamentos. Ademais, antes de iniciar um programa de matriciamento é importante conhecer as deficiências do grupo de médicos participantes, já que os grupos matriciados podem ser heterogêneos quanto ao conhecimento em nefrologia.
Introduction: In Brazil, the regional distribution of physicians is uneven and there is a shortage of some specialists. Nephrology represents only 1.1% of medical specialties1 , and in addition to the shortage of specialists, the most prevalent pathology in nephrological care, chronic kidney disease (CKD), has had a growing increase in incidence and prevalence rate. The importance of proper management in chronic kidney disease patients will reflect both in the delay of disease progression and in the survival of patients in more advanced stages. In this scenario appears the matrix support by the nephrologist to primary health care (PH) physicians, which consists in a new model to produce health, in a process of shared construction with a proposal of pedagogical and therapeutic intervention, which approaches PH physicians to the specialist, through meetings called Matrix Support. Objective: To evaluate the impact of matrix support in nephrology as to the adequacy of referral to the specialist and the urgent initiation of renal replacement therapy in patients from referral hospitals in the city of Bauru. Secondary objective: to evaluate the knowledge in nephrology of PH physicians before and during the matrix support. Methodology: This is a time series intervention study regarding the implementation of matrix support in nephrology, which was carried out in the outpatient medical specialties clinic (AME) in the city of Bauru, São Paulo state, starting in July 2019 to June 2020. The adequacy of referrals to the nephrologist at AME Bauru in the one-year period before and after the matrix support were compared, considered adequate those that meet the criteria based on the protocols for referral to the nephrologist of the Ministry of Health. The rates and data on the laboratory and clinical profile of patients incident to urgent onset renal replacement therapy (RRT) in dialysis centers of reference hospitals for patients of the Unified Health System (SUS) were also evaluated, through consultation in medical records, for a period of one year before and two years after the beginning of the matrix support. The medical knowledge in nephrology of the PH physicians was evaluated by means of 15 questions about nephrology applied in the first 11 and last meeting after the one-year period. Results: After the intervention, referral to the nephrologist in an appropriate manner proved to be higher (51.56% vs 79.68%, p=0.002). Regarding the characteristics of referred patients, we observed a similar demographic profile, with change in renal function as the main reason for referral to the nephrologist. The groups differed regarding the initial diagnosis, with CKD stage III being the main in the group of patients referred before matrix support and stage IV after the start of matrix support. After the intervention, there were higher referrals to the pre-dialysis outpatient clinic (3.1% vs 17.2%, p=0.0019). There was a reduction in the prevalence of patients who started urgent onset RRT in the municipality of Bauru in the period after the intervention (86.42% vs 68.96%, p=<0.001). No significant differences were observed among patients who initiated RRT regarding demographic, clinical or laboratory characteristics. Physician knowledge about topics in nephrology differed between the two groups of physicians evaluated at the beginning and end of the matrix support. The group after the matrix support had a higher number of errors in general and in CKD and hematuria, while the group before the matrix support had a higher number of errors in renal lithiasis. Conclusion: Although the COVID 19 pandemic hindered the study, it can be observed that the matrix support in nephrology was effective in improving the adequacy of referrals to the nephrologist as well as in reducing the incidence of patients who started dialysis urgently, promoting better health conditions with the assertiveness of referrals. Moreover, before starting a matrix support program, it is important to know the deficiencies of the group of participating physicians, since the matriculated groups may be heterogeneous in terms of knowledge in nephrology Keywords: matrix support in neph
Introduction: In Brazil, the regional distribution of physicians is uneven and there is a shortage of some specialists. Nephrology represents only 1.1% of medical specialties1 , and in addition to the shortage of specialists, the most prevalent pathology in nephrological care, chronic kidney disease (CKD), has had a growing increase in incidence and prevalence rate. The importance of proper management in chronic kidney disease patients will reflect both in the delay of disease progression and in the survival of patients in more advanced stages. In this scenario appears the matrix support by the nephrologist to primary health care (PH) physicians, which consists in a new model to produce health, in a process of shared construction with a proposal of pedagogical and therapeutic intervention, which approaches PH physicians to the specialist, through meetings called Matrix Support. Objective: To evaluate the impact of matrix support in nephrology as to the adequacy of referral to the specialist and the urgent initiation of renal replacement therapy in patients from referral hospitals in the city of Bauru. Secondary objective: to evaluate the knowledge in nephrology of PH physicians before and during the matrix support. Methodology: This is a time series intervention study regarding the implementation of matrix support in nephrology, which was carried out in the outpatient medical specialties clinic (AME) in the city of Bauru, São Paulo state, starting in July 2019 to June 2020. The adequacy of referrals to the nephrologist at AME Bauru in the one-year period before and after the matrix support were compared, considered adequate those that meet the criteria based on the protocols for referral to the nephrologist of the Ministry of Health. The rates and data on the laboratory and clinical profile of patients incident to urgent onset renal replacement therapy (RRT) in dialysis centers of reference hospitals for patients of the Unified Health System (SUS) were also evaluated, through consultation in medical records, for a period of one year before and two years after the beginning of the matrix support. The medical knowledge in nephrology of the PH physicians was evaluated by means of 15 questions about nephrology applied in the first 11 and last meeting after the one-year period. Results: After the intervention, referral to the nephrologist in an appropriate manner proved to be higher (51.56% vs 79.68%, p=0.002). Regarding the characteristics of referred patients, we observed a similar demographic profile, with change in renal function as the main reason for referral to the nephrologist. The groups differed regarding the initial diagnosis, with CKD stage III being the main in the group of patients referred before matrix support and stage IV after the start of matrix support. After the intervention, there were higher referrals to the pre-dialysis outpatient clinic (3.1% vs 17.2%, p=0.0019). There was a reduction in the prevalence of patients who started urgent onset RRT in the municipality of Bauru in the period after the intervention (86.42% vs 68.96%, p=<0.001). No significant differences were observed among patients who initiated RRT regarding demographic, clinical or laboratory characteristics. Physician knowledge about topics in nephrology differed between the two groups of physicians evaluated at the beginning and end of the matrix support. The group after the matrix support had a higher number of errors in general and in CKD and hematuria, while the group before the matrix support had a higher number of errors in renal lithiasis. Conclusion: Although the COVID 19 pandemic hindered the study, it can be observed that the matrix support in nephrology was effective in improving the adequacy of referrals to the nephrologist as well as in reducing the incidence of patients who started dialysis urgently, promoting better health conditions with the assertiveness of referrals. Moreover, before starting a matrix support program, it is important to know the deficiencies of the group of participating physicians, since the matriculated groups may be heterogeneous in terms of knowledge in nephrology Keywords: matrix support in neph
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Palavras-chave
Apoio matricial em nefrologia, Matriciamento, Doença renal crônica, Matrix support in nephrology, Matrix support, Chronic kidney disease