Identificação de barreiras para atendimento oftalmológico dentro do Sistema Único de Saúde
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Data
2018-07-31
Autores
Rezende, Marcelo Abrão
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Universidade Estadual Paulista (Unesp)
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Introdução: O atendimento oftalmológico prestado pelas diferentes cidades no território nacional difere na oferta de serviços e complexidade. Além disso, a oftalmologia é uma especialidade altamente dependente de equipamentos para a prestação da assistência. Assim, os municípios menores e com menos recursos, muitas vezes, ficam desassistidos. Nesse sentido, a atuação de unidades móveis oftalmológicas (UMO) equipadas para a realização de exames refracionais poderiam reduzir a demanda para serviços terciários e reduzir algumas das barreiras para o atendimento oftalmológico dentro do Sistema Único de Saúde (SUS). No entanto, mesmo com o atendimento prestado pela UMO e encaminhamento dos casos mais complexos ao serviço terciário, alguns pacientes não comparecem ao serviço de referência. Objetivo: Verificar as causas para a não adesão ao encaminhamento ao serviço de referência para tratamento das possíveis causas de cegueira/ deficiência visual, detectadas na comunidade por meio de triagem oftalmológica realizada pela UMO. Material e Métodos: Estudo prospectivo e observacional realizado com pacientes atendidos pela UMO em 10 municípios do centro-oeste paulista no ano de 2015. Após atendimento realizado pela UMO nos municípios, os pacientes que necessitaram de cuidados no nível terciário foram encaminhados para o centro de referência da região, o Hospital das Clínicas de Botucatu (HC-FMB). Porém, alguns pacientes não aderiram ao encaminhamento e estes foram o objeto deste estudo. Procurou-se identificar os motivos de não adesão e as barreiras para o atendimento oftalmológico através de duas diretrizes: (1) análise comparativa dos dados dos pacientes encaminhados e dos pacientes que não compareceram ao serviço de referência; (2) aplicação de um questionário aos indivíduos faltosos, localizados através de busca ativa. A busca ativa foi realizada com auxílio das Secretarias de Saúde dos respectivos municípios e do serviço social do HC-FMB ou por meio de contato telefônico direto com o indivíduo faltoso. Além disso, foram utilizados dados demográficos do Instituto Brasileiro de Geografia e Estatística para avaliação das condições de assistência oftalmológica de cada um dos municípios participantes. Análise estatística realizada no SPSS 22.0, considerado significativo p<0,05. Resultados: Foram atendidos 1928 indivíduos pela UMO, sendo encaminhados 714 (37,0%) ao serviço especializado. Dos pacientes encaminhados, 227 (31,8%) não compareceram ao serviço referenciado. A média de idade dos pacientes encaminhados foi de 57,12±19,53 anos, sendo 59,9% do sexo feminino, com acuidade visual (AV) corrigida no melhor olho de 0,37±0,36 logMAR, sendo 47 (6,6%) cegos e 185 (26,5%) deficientes visuais. Entre os pacientes que não compareceram, a média de idade foi de 56,08±16,23, sendo 62,9% do sexo feminino, com a AV com correção no melhor olho, de 0,36±0,22 logMAR, sendo 12 (5,4%) cegos e 48 (21,6%) deficientes visuais. Entre os 12 pacientes que preenchiam os critérios para cegueira e que não compareceram ao encaminhamento, 10 (83,3%) apresentavam causas reversíveis de cegueira. A não adesão ao encaminhamento variou de 16,8% a 46,8% conforme o munícipio de origem. Dos 227 pacientes que não compareceram ao serviço, 101 (44,5%) deveriam comparecer ao ambulatório de catarata; 67, (29,5%) ao ambulatório de plástica ocular/doenças externas; 34, (14,9%) ao ambulatório de glaucoma; 9, (3,9%) ao ambulatório de estrabismo; 8, (3,5%) ao ambulatório de retina; e 8 (3,5%) ao ambulatório de córnea. A busca ativa dos 227 pacientes que não compareceram ao atendimento referenciado localizou 140 (62%) pacientes. Os motivos de não comparecimento mais referidos pelos pacientes foram: 31 (22,1%) procuraram outro serviço (particular ou terciário), 17 (12,1%) outros motivos, 16 (11,4%) por doença/motivo que incapacita viajar, 15 (10,7%) faleceram ou mudaram de endereço ou cidade e 14 (10,0%), por não entenderem as explicações do médico. Conclusão: A adesão ao tratamento oftalmológico, após o diagnóstico da condição ocular feito utilizando uma unidade móvel, é dependente de fatores relacionados ao próprio paciente ou relacionada a falta de conhecimento das afecções oftalmológicas que podem levar a cegueira. Há necessidade de campanhas de conscientização para que a adesão aos tratamentos propostos possa ser mais satisfatória.
Introduction: Different cities differ according to the offering of ophthalmic care services and complexity in the national territory. Ophthalmology is a specialty highly dependent on equipment for the provision of healthcare. Thus, smaller and less resourceful cities often remain unattended. In this sense, the operation of mobile ophthalmologic units (MOU) equipped for refractive exams could reduce the demand for tertiary services and reduce some of the barriers to ophthalmologic care within the Unified Health System (in Brazil, SUS). However, even with the assistance provided by the mobile units and the referral of the more complex cases to the tertiary service some patients do not attend the referral service. Objective: To verify the causes of non-attendance to the referral service at the tertiary facility to treat possible causes of blindness / visual impairment detected in the community through ophthalmologic screening performed by the MOU. Material and Method: Prospective and observational study was carried out with patients assisted by the MOU in 10 municipalities in the center-west of São Paulo in the year 2015. After care given by the MOU in the cities, the patients who needed care at the tertiary level were directed to the referral center of the region, the Hospital das Clínicas de Botucatu (HC-FMB). However, some patients did not adhere to the referral and these were the object of this study which was developed to identify the reasons for non-adhesion and the barriers to ophthalmologic care through two guidelines: (1) comparative analysis of data from patients referred and patients who did not attend the referral service; (2) application of a questionnaire to the faulty individuals, located through active search. The active search was carried out using the Health Secretariats of the respective municipalities and the HC-FMB social service and through direct telephone contact with the missing individual. In addition, demographic data from the Brazilian Institute of Geography and Statistics were used to evaluate the ophthalmological assistance conditions of each of the participating municipalities. Statistical analysis was performed using SPSS 22.0, considering significant p <0.05. Results: One-thousand-nine hundred and twenty eight individuals were attended by the MOU being 714 (37.0%) referred to the specialized service. From the patients referred, 227 (31.8%) did not attend the referral. The mean age of the referred patients was 57.12 ± 19.53 years, 59.9% of which were female, with best correct visual acuity (BCVA) in the good eye of 0.37 ± 0.36 logMAR, of which 47 (6.6%) were blind and 185 (26.5%), visual impaired. Among the patients who did not attend, the average age was 56.08 ± 16.23, being 62.9% female, with BCAV in the good eye, of 0.36 ± 0.22 logMAR, being 12 (5.4%) blind and 48 (21.6%), visual impaired. Among the 12 patients who met the criteria for blindness and who did not attend to the referral, 10 (83,3%) presented reversible causes of blindness. Non-adhesion to the referral ranged from 16.8% to 46.8% according to the municipality. Of the 227 patients who did not attend the service, 101 (44.5%) should attend the cataract outpatient clinic; 67, (29.5%) to the ocular plastic surgery clinic / external diseases; 34, (14.9%) to the glaucoma outpatient clinic; 9, (3.9%) to the strabismus clinic; 8, (3.5%) to the retina clinic; and 8 (3.5%) to the cornea clinic. With active search of the 227 patients who did not attend the service it was possible to identify 140 (62%) patients. The reason for non-attendance were: 31 (22.1%) decided to go to another service (private or tertiary), 17 (12.1%) other reasons, 16 (11.4%) for illness / reason that disables of travel, 15 (10.7%) died or changed their address or city and 14 (10.0%), because they did not understand the doctor's explanations. Conclusion: The adherence to ophthalmologic treatment, after diagnosis of the ocular condition made using a MOU, is dependent on factors related to the patient or related to the lack of knowledge of the ophthalmological conditions that can lead to blindness. There is a need for awareness campaigns so that adherence to the proposed treatments may be more satisfactory.
Introduction: Different cities differ according to the offering of ophthalmic care services and complexity in the national territory. Ophthalmology is a specialty highly dependent on equipment for the provision of healthcare. Thus, smaller and less resourceful cities often remain unattended. In this sense, the operation of mobile ophthalmologic units (MOU) equipped for refractive exams could reduce the demand for tertiary services and reduce some of the barriers to ophthalmologic care within the Unified Health System (in Brazil, SUS). However, even with the assistance provided by the mobile units and the referral of the more complex cases to the tertiary service some patients do not attend the referral service. Objective: To verify the causes of non-attendance to the referral service at the tertiary facility to treat possible causes of blindness / visual impairment detected in the community through ophthalmologic screening performed by the MOU. Material and Method: Prospective and observational study was carried out with patients assisted by the MOU in 10 municipalities in the center-west of São Paulo in the year 2015. After care given by the MOU in the cities, the patients who needed care at the tertiary level were directed to the referral center of the region, the Hospital das Clínicas de Botucatu (HC-FMB). However, some patients did not adhere to the referral and these were the object of this study which was developed to identify the reasons for non-adhesion and the barriers to ophthalmologic care through two guidelines: (1) comparative analysis of data from patients referred and patients who did not attend the referral service; (2) application of a questionnaire to the faulty individuals, located through active search. The active search was carried out using the Health Secretariats of the respective municipalities and the HC-FMB social service and through direct telephone contact with the missing individual. In addition, demographic data from the Brazilian Institute of Geography and Statistics were used to evaluate the ophthalmological assistance conditions of each of the participating municipalities. Statistical analysis was performed using SPSS 22.0, considering significant p <0.05. Results: One-thousand-nine hundred and twenty eight individuals were attended by the MOU being 714 (37.0%) referred to the specialized service. From the patients referred, 227 (31.8%) did not attend the referral. The mean age of the referred patients was 57.12 ± 19.53 years, 59.9% of which were female, with best correct visual acuity (BCVA) in the good eye of 0.37 ± 0.36 logMAR, of which 47 (6.6%) were blind and 185 (26.5%), visual impaired. Among the patients who did not attend, the average age was 56.08 ± 16.23, being 62.9% female, with BCAV in the good eye, of 0.36 ± 0.22 logMAR, being 12 (5.4%) blind and 48 (21.6%), visual impaired. Among the 12 patients who met the criteria for blindness and who did not attend to the referral, 10 (83,3%) presented reversible causes of blindness. Non-adhesion to the referral ranged from 16.8% to 46.8% according to the municipality. Of the 227 patients who did not attend the service, 101 (44.5%) should attend the cataract outpatient clinic; 67, (29.5%) to the ocular plastic surgery clinic / external diseases; 34, (14.9%) to the glaucoma outpatient clinic; 9, (3.9%) to the strabismus clinic; 8, (3.5%) to the retina clinic; and 8 (3.5%) to the cornea clinic. With active search of the 227 patients who did not attend the service it was possible to identify 140 (62%) patients. The reason for non-attendance were: 31 (22.1%) decided to go to another service (private or tertiary), 17 (12.1%) other reasons, 16 (11.4%) for illness / reason that disables of travel, 15 (10.7%) died or changed their address or city and 14 (10.0%), because they did not understand the doctor's explanations. Conclusion: The adherence to ophthalmologic treatment, after diagnosis of the ocular condition made using a MOU, is dependent on factors related to the patient or related to the lack of knowledge of the ophthalmological conditions that can lead to blindness. There is a need for awareness campaigns so that adherence to the proposed treatments may be more satisfactory.
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Palavras-chave
Serviços de Saúde Ocular, Cegueira, Acesso aos Serviços de Saúde, Barreiras aos serviços oftalmológicos, Sistema Único de Saúde, Ocular Health Services, Blindness, Access to Health Services, Barriers to ophthalmological services, Unified Health System