Brazilian Survey on Preventive Actions for the Population With Access to Primary Healthcare: Inefficient Spending in a Country in Economic Crisis.

Patrícia Sampaio Chueiri,Erno Harzheim,Lucas Wollmann,Rodrigo Aquino Martins Da Silva,Anna Dilda,Sotero Mengue,Lisiane Hauser,Rudi Roman,Marcelo Rodrigues Gonçalves,Milena Agostinho

doi:10.34172/ijhpm.2021.94

Abstract

Cancer ranks second as a cause of death in Brazil. Although preventive practices are part of the daily routine of primary healthcare (PHC) teams, organized screening programs are lacking. This study aimed to evaluate the adequacy of preventive interventions in the main cancer types, as defined by the Brazilian government. We analyzed cross-sectional data from a larger project conducted in 2016 with PHC service users and physicians from all over Brazil, interviewed by trained research staff. The sample was stratified by the number of PHC physicians per geographic region, who were eligible for inclusion if they had been working in the same PHC unit for at least one year. Twelve adult patients with at least two encounters were included per participating physician. Only the data from service users were analyzed in this study. We evaluated the questions about preventive practices and calculated the following indicators: coverage, focus, screening errors, and screening ratio. National guidelines and international evidence were used as a comparison parameter. The study population consisted of 6160 service users. The data indicate that the recommendations for cervical, breast, and prostate cancer screening and for treatment of tobacco dependence are not adequately followed. Coverage for breast and cervical cancer screening presented an overutilization bias, with rates 50% and 9% above the expected, respectively. The screening focus was also inadequate: 24%, 47%, and 54% of the screening tests for the three cancer types were performed in individuals outside the recommended age range. 31% of smokers were not approached for treatment. These findings indicate that the Brazilian population has been subjected to inadequate and potentially iatrogenic interventions in PHC. New policies based on stricter criteria of adequacy and increased use of the concept of quaternary prevention may improve the effectiveness and equity of the health system.

Highlights

Cancer ranks second as a cause of death in Brazil, and an estimated 625 000 new cases will be diagnosed in the year 2020.1 In this area, Brazil faces a challenge similar to that of the triple burden of disease, when the country needs to organize the health system to assist people with infectious diseases, chronic diseases, and external causes, which is a typical characteristic of developing countries
The results show that Brazilian primary healthcare (PHC) teams have not followed official recommendations, and many service users have been subjected to actions that can cause more harm than good, in addition to reducing the efficacy of the health system
The present study population consisted of 6160 PHC service users who were interviewed in the umbrella project from July to December 2016, which accounted for 99.5% of the required sample size

Summary

Introduction

Cancer ranks second as a cause of death in Brazil, and an estimated 625 000 new cases will be diagnosed in the year 2020.1 In this area, Brazil faces a challenge similar to that of the triple burden of disease, when the country needs to organize the health system to assist people with infectious diseases, chronic diseases, and external causes (violence and accidents), which is a typical characteristic of developing countries. Organized screening programs can have a positive impact on cancer-specific mortality and improve quality of life in some types of cancer.[2] the effectiveness of an organized screening program is dependent on the quality of each process step: selection of the target population, choice of screening method and interval defined by the best evidence, establishment and audit of quality standards, continuous monitoring and evaluation, and adequate infrastructure and financial resources Without these conditions, screening poses a potential risk of overdiagnosis and overtreatment for patients, and the program becomes inefficient for the health system.[3] Organized screening programs with a positive effect include screening for cervical cancer, colorectal cancer, and less robustly, screening for breast cancer.[3,4,5]

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