Portuguese Health System Research Articles

What weights on the user experience of hospital inpatient episodes? A Portuguese national study

Abstract Background Information about the users' experience is an essential element in patient-centered healthcare. We determined the score of the different elements of inpatient experiences of admission episodes in hospitals of the Portuguese health system and examined their contribution to the overall experience score. Methods A national cross-sectional study using randomized telephone interviews was conducted in the general population for the last episode of individuals who had an episode of hospitalization care between November 2016 and October 2017. Descriptive analysis of sociodemographic characteristics, care episode, hospital, elements of experience (16 dimensions), and global opinion was performed. The elements of experience were compared with the global experience through Spearman's correlation, with the contribution of each element to the global opinion calculated through weighted least squares regression. Results We obtained a total of 308 responses, 60.7% were female and the average age was 53.1 years, the average length of stay was 8.06 days; 35.1% were in medical departments; 56.5% were elective; 43.8% hospitals were in the Lisbon Metropolitan Area and 88.3% were from the public health service. All elements of experience and the overall opinion presented median values between 3 and (the maximum) 4. The correlation of each element with the global opinion is positive and statistically significant, having a contribution to the global opinion which varies between 11.5% and 51.6%, independently of demographic, episode of care or hospital characteristics. The domains of emotional support, empathy and respect; and communication, information and personal interaction make the greatest contribution to global opinion. Conclusions Elements of experience do not have the same weight on the global evaluation of inpatient individuals, which seem to privilege relational and interpersonal aspects of care. These findings have implications for patient-centered healthcare. Key messages Most users are satisfied with their hospitalization episodes of the Portuguese health system. The elements that contribute the most to the experience have to do with the healthcare workforce and their interaction with the users.

COVID-19: What Is Next for Portugal?

Highly infectious with the possibility of causing severe respiratory complications, the novel COVID-19 began stretching health systems beyond their capacity all over the world and pushing them to breaking points. Giving the devastating effects caused by this infection, unprecedented measures have to be adopted in order to mitigate its impacts on the health system. This perspective aims to review the epidemic of COVID-19 in Portugal, possible areas of improvement, and potential interventions that can help to mitigate the effect of COVID-19 on the Portuguese health system.

A Hospitalização Domiciliária na Pandemia COVID-19

A hospitalização domiciliária tem vindo a implementar-se no sistema de saúde português como um modelo de assistência de nível hospitalar no domicílio. É uma alternativa ao internamento convencional, para doentes agudos ou crónicos agudizados, sendo a admissão nesta tipologia de internamento voluntária. Devem estar garantidos os critérios de admissão, que passam essencialmente pela estabilidade clínica com comorbilidades controláveis no domicílio, presença de cuidador e domicílio com boas condições de higiene e segurança, e domicílio na área de influência da unidade hospitalar de referência. As vantagens da hospitalização domiciliária parecem ser evidentes, nomeadamente no que toca à significativa redução das infeções nosocomiais, quedas e episódios de síndroma confusional aguda. No atual contexto da pandemia COVID-19, a hospitalização domiciliária pode ser parte da solução de resposta do sistema de saúde, não só pelo aumento da capacidade de internamento domiciliário de doentes sem infeção por SARS-CoV-2 mas também, cumprindo todas as recomendações de segurança, ser uma possibilidade de internamento para doentes com infeção por SARS-CoV-2 após, pelo menos, 7 dias de internamento hospitalar convencional com estabilidade clínica, possibilidade de isolamento e cuidador não portador de condição de saúde vulnerável. A equipa de saúde da hospitalização domiciliária assume aqui um papel-chave na educação e promoção da saúde, proporcionando aprendizagens no que toca às medidas de isolamento, higiene das mãos e etiqueta respiratória. Cumpridos os critérios de admissão, a hospitalização domiciliária é uma tipologia de internamento que permite atingir a eficiência sem prejuízo da segurança do doente.

Health Systems and Nursing Skills in Portugal.

The paper discusses the Portuguese Health System that has adopted the Beveridge model, which is based on the financing of health services by taxpayers' income, based on a public system, where the right to health is independent of work and employment. Nursing education is structured in Pre-Graduate Education - Degree; Master and Doctorate in Nursing Sciences and Nursing. The competency of the generalist nurses refers to the professional performance showing the effective application of knowledge and skills, which allows them to make a clinical judgment and decide. The exercise of competencies is based on the interpersonal relationship between the nurse and the individual client or group; decision-making based on scientific evidence, clinical judgment based on the needs of individual or group care, prescribed nursing interventions considering the safety of care and the client, early detection of the real or diagnostic potentials seeking resolution or minimization of consequences, by the values of the patients, as well as respect and professional regulation that establish good practice.

Healthcare Use in Multimorbidity Patients

Abstract Background The existence of multiple chronic conditions in the same patient is a public health problem, recognized as relevant to health systems. Individuals with multimorbidity have additional health needs, which in the context of continuous increase of life expectancy, imply a heavy burden to healthcare services. Methods We analysed the association between healthcare use (primary care, medical specialist consultations and hospitalizations) and multimorbidity in the Portuguese population aged 25-74 years old, using the Health Examination Survey (n = 4911) data. Logistic regression models adjusted for predisposing (age, education) and enabling (income, region of residence) factors were fitted separately for male and female. Odds ratios and CI95% were estimated. Results Prevalence of multimorbidity was 38.3% (95%CI: 35.4%; 41.3%). In males, after adjustment for confounding and when compared to patients without chronic conditions, multimorbidity was associated with greater use of primary care (OR = 3.7; CI95%: 2.3-5.8), medical specialist consultations (OR = 1.9; CI95%: 1.1-3.4) and hospitalizations (OR = 1.8; CI95%: 1.2-2.7). In female, statistically significant association between multimorbidity and healthcare use was observed for primary care (OR = 2.6; CI95%: 1.6-4.3) and medical specialist consultations (OR = 2.8; CI95%: 2.0-3.9), but not for hospitalizations. Both male and female with multimorbidity reported greater use of primary care, compared to individuals with only one chronic condition (OR = 2.4; CI95%: 1.3-4.4 and OR = 1.7; CI95%: 1.1-2.8, respectively). Conclusions Our results show a greater healthcare use in patients with multimorbidity, both in primary and hospital care. The availability of scientific evidence regarding the healthcare use, by patients with multimorbidity, may substantiate the discussion about the possible need for the Portuguese health system to adapt to these patients, with changes in policies that will allow better and more efficient treatment. Key messages This study may support the discussion about the adaptation of Portuguese health system to patitents with multimorbidity. Further discussion on policy change is needed, targeting an efficient management of these patients.

The health care reform in Portugal: Outcomes from both the New Public Management and the economic crisis

The Portuguese health system concentrates most of its activity in a National Health Service, created in 1979 to promote universal and general access. The National Health Service should ensure equity, efficiency, and quality of all health care delivered services. This study assesses the impact of health care policies between 2002 and 2017, focusing on 3 timeframes: the adoption and adaptation of New Public Management principles to the health care sector (2002 to 2010), the economic and financial crisis period (2011-2015), and the postcrisis recovery period (2016-2017). The current study evaluates the main policy measures in the health sector, presenting their impacts in terms of access, efficiency, accountability, and costs over those 3 economic periods. It was verified that not all the measures implemented by the successive governments obtained the desired outcomes, generating even costs increase, apart from the austerity period in which health expenditure showed a significant reduction because of the financial constraints.

La atención primaria en Portugal

The economic crisis and deterioration of the Portuguese National Health service has forced professionals to leave the country. The Portuguese National Health System was introduced in 1976, but it has been unable to provide citizens with the social and health advantages of an equality of access and free national health system.The Portuguese National Health System is financed by taxes. However, a 35% of its incomes are from private sources. The health minister decides the budget, and it is based on an historical financing plus a per capita system. Portuguese citizens and immigrants are entitled to free health care, but there is a co-payment for care, diagnostic, pharmacy, and emergency care. Health care provision is a mixture of public and private health care at a regional level. It leads to fragmentation of services and greater inequalities. Doctors are civil servants. Salary is regulated and it depends on seniority and on-call shifts. Primary care activities are similar to those of their Spanish counterparts. General practitioners have gatekeeper function, but the system is imperfect, and patients with private insurance get direct access to the specialist. Specialist training is similar to the training system in Spain. Continuing education is not regulated. The Portuguese Health System has been trying to become a national health system since 1979. Political instability, fragmentation of services, lack of clarity between public and private and co-payments are important constraints. Inequalities are an important problem to reconsider while discussing a national health system.

Cost-effectiveness of the 13-valent Pneumococcal Conjugate Vaccine in Children in Portugal.

Pneumococcal infections are the leading cause of vaccine-preventable death in children. In June 2015, the 13-valent pneumococcal conjugate vaccine (PCV13) was introduced in the Portuguese Immunization Program. We evaluated the cost-effectiveness of children vaccinated with PCV13 versus no vaccination for preventing pneumococcal diseases. A cohort simulation model for 2014 Portuguese newborns was used, considering a lifetime horizon and existence of herd effect on adults. Model outcomes measured life years gained, direct and indirect healthcare costs and net benefits considering &OV0556;20,000 per life years gained. PCV13 clinical effectiveness rate by serotype covered was assumed similar to PCV7. Patients' resource use was based on 2014 diagnostic-related group database and experts' opinion, while national legislation and official drug cost database were the main sources for unitary costs. Univariate sensitivity analyses were conducted to assess results' effectiveness. In base case scenario, PCV13 was a dominant strategy, being associated with better health outcomes and lower costs. In a lifetime, a total of 6238 infections (excluding acute otitis media) and 130 deaths were averted, with a total saving of &OV0556;397,217 ($432,966). Net benefits were estimated above &OV0556;28 million ($30 million). Results were robust in all sensitivity analyses, with positive net benefits, except when herd effect was excluded. Vaccination of children with PCV13 starting in their first year of life is a cost-effective intervention with the potential to save costs to the Portuguese health system and to provide health gains by reducing the burden of pneumococcal disease in the vaccines and through the herd effect of this vaccine.

A Spatial Econometric Analysis of the Calls to the Portuguese National Health Line

The Portuguese National Health Line, LS24, is an initiative of the Portuguese Health Ministry which seeks to improve accessibility to health care and to rationalize the use of existing resources by directing users to the most appropriate institutions of the national public health services. This study aims to describe and evaluate the use of LS24. Since for LS24 data, the location attribute is an important source of information to describe its use, this study analyses the number of calls received, at a municipal level, under two different spatial econometric approaches. This analysis is important for future development of decision support indicators in a hospital context, based on the economic impact of the use of this health line. Considering the discrete nature of data, the number of calls to LS24 in each municipality is better modelled by a Poisson model, with some possible covariates: demographic, socio-economic information, characteristics of the Portuguese health system and development indicators. In order to explain model spatial variability, the data autocorrelation can be explained in a Bayesian setting through different hierarchical log-Poisson regression models. A different approach uses an autoregressive methodology, also for count data. A log-Poisson model with a spatial lag autocorrelation component is further considered, better framed under a Bayesian paradigm. With this empirical study we find strong evidence for a spatial structure in the data and obtain similar conclusions with both perspectives of the analysis. This supports the view that the addition of a spatial structure to the model improves estimation, even in the case where some relevant covariates have been included.

Services utilization for mental health problems in Portugal during the economic crisis: Preliminary results of the national mental health survey follow-up

IntroductionDuring economic crises additional mental health risks emerge and social inequalities in health can widen. In order to ensure universal coverage of mental health care and to reduce the impact of the crisis, it is crucial to assess the needs of the population to be able to reorganize mental health care accordingly.ObjectivesTo analyse the use of services for mental health problems in Portugal during the economic crisis.MethodsIn this follow-up epidemiological study, a probability sub-sample of respondents to the 2008 national mental health survey (n = 911) was re-interviewed in 2015. Socio-demographic variables and treatment patterns were assessed using a structured interview, and psychological distress was measured using the Kessler-10 Scale. Descriptive analysis was conducted to characterize the use of services for mental health problems.ResultsIn total, 27.9% of the respondents sought treatment for mental health problems in the previous 5 years, and GPs were the most contacted professionals. Only 57.7% (n = 119) of the respondents with moderate or severe psychological distress (n = 197) reported recognizing they needed treatment. Among people with moderate or severe psychological distress who recognized their need for treatment, most received treatment (80.5%, n = 105), which was minimally adequate for 74.4% (n = 81). Low perceived need and structural barriers were the main obstacles for access to care.ConclusionsUnder-treatment, low continuity of care and low adequacy of treatment are problems that the Portuguese health system must address in order to meet the mental health challenges of the economic crisis.FundingEEA Grants: Programa Iniciativas em Saúde Pública.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Scientific Research Policy for Health in Portugal: II - Facts and Suggestions

After more than 40 years of democracy and 30 years of European integration, Portugal has bridged the research gap it had previously. However, when compared to global and European research policies, Portugal still has a long way go regarding investment in research and development. Health Research in Portugal has been managed by the Fundação para a Ciência e Tecnologia and the National Health Institute Doctor Ricardo Jorge, and it has not been a political priority, emphasized by the absence of a national scientific research plan for health, resulting in a weak coordination of actors in the field. The strategic guidelines of the 2004 - 2010 National Health Plan are what comes closest to a health research policy, but these were not implemented by the institutions responsible for scientific research for the health sector. Trusting that adopting a strategy of incentives to stimulate health research is an added-value for the Portuguese health system, the authors present five strategic proposals for research in health in Portugal.

How multiple chronic conditions increase the risk of ACSC hospitalizations

Introduction : The high financial burden of avoidable hospitalizations has led to an increase of the study of hospitalizations for ambulatory care sensitive conditions (ACSC). Although patients’ social and demographic characteristics are frequently identified in the literature as factors that increase the risk of an avoidable hospitalization, there is little information on the impact of multiple chronic conditions on these hospitalizations. Our study looks for the relationship between multiple chronic conditions and ACSC hospitalizations. Theory/Methods : Data consists of all hospitalizations in the portuguese health system between 2008 and 2012. Avoidable hospitalizations were identified according to the Canadian Institute for Healthcare Information and chronic conditions were identified according to criteria set by the Agency for Healthcare Research and Quality. A retrospective study analyzing all patients hospitalized for an ACSC and all patients hospitalized for non-ACSC was made, using different multiple logistic regression models to identify the impact of chronic conditions in the risk of admission. Results : We found that the population with ACSC hospitalizations when compared to the population with non-ACSC hospitalizations has in average more chronic conditions (3.93 to 1.98, p=0.008) and chronic conditions in more body systems (2.50 to 1.49, p=0.00419). We observed that the probability of an ACSC hospitalization increases 1.35 times (p Conclusion : The number of chronic conditions and the type of body systems affected increases the risk of admission for ACSC. Further investigation needs to follow in order to develop risk models that help both identify these patients in higher risk of an avoidable hospitalization and promote a more assertive use of ACSC as measure of access to care.

Is there room for case managers in Portugal?

Introduction : Recently, there were implemented several reforms in the Portuguese Health System, in the context of the 2011-2014 hospital reform. One of the main lines of action is the integration of care to optimize resources utilization while improving quality of care. A working group report found almost nonexistent evidence on integration of care in Portugal and recommended the development of case management concept. To pursue the integration of care policy, this recommendation was approved and supported by the Ministry of Health. Description of the policy, objectives and target population To implement the case mangers policy, a multidisciplinary team is following the 4 phases development model for integrated care (Minkman et al.; 2013). The first approach was to define the specific roles of case managers, based on literature review and taking into account the current roles of Portuguese health and social care professionals. The search on pubmed and grey literature retrieved 46 papers/reports. After the definition of the main roles and the target population, case management policy is developed as a pilot experience in a Local Health Unit. The main goal is to improve continuity of care and patient centered care, namely for priority patients with multimorbidity and special health and social needs, improving quality while reducing hospital utilization. The target population, in the first phase, is the frequent users of the emergency room (ER), defined as going 4 or more times to ER in the same year (Pepe et al., 2007). We selected and assessed 3 case studies for case management. The differentiating factor of this policy is the holistic approach, focusing not on the management of one disease, but on the management of the patient with all of his diseases and needs. Key findings : Although the concept of case management is widely spread around the world, we found that literature is scarce concerning the specific roles of case managers and it depends on the context in which it is implemented. The specific roles of case managers in the Portuguese context are the following: - Referral process follow up; - Coordinate care, facilitating collaboration and communication among different professionals (health and social care); - Define a personalized intervention plan; - Empower patients and their families, through self-care and self-management of the diseases; - Suport familiy and carers; - Ensure therapeutic adherence; - Follow up the patient through all levels of care, from the outpatient context to inpatient admission and collaboration in the discharge planning; - Follow up the patient after hospital discharge; - Manage services and resources utilization following clinical guidelines and clinical pathways; - Ensure quality of care, according to best standards, taking patient choices into account; - Report outcomes; Regarding outcomes assessment, we monitor the following indicators: emergency admissions of the target patients, number of inpatient admissions, 30 days readmissions, avoidable admissions, a consultation with the family doctor until 30 days after hospital discharge, time of hospital discharge postponement and patient satisfaction. The expected impact is the improvement of care coordination, a better control of patients with chronic diseases, decrease of avoidable admissions (to the ER and inpatient admissions) and quality of life enhancement. Highlights : The development of the case management policy is in the first steps in Portugal. It needs to be deepened and further tested. Success criteria should be accessed. Conclusion : In Portugal, evidence of integrated care is scarce. Case management is a new policy supported by the Ministry of Health that is being implemented to improve integration of care. The definition of the case manager specific role in the portuguese context might contribute to the enlarged discussion, since there is few evidence about this subject. The pilot experience allows assessing results and success criteria so that it can be transferred to other regions.

Portuguese Health System, an Overview and a SWOT Review

Purpose: The aim of this work is to describe the Portuguese health system and to provide a SWOT approach of its present situation. In this way, a clear and simplified picture of the health system can be offered and some strategies are proposed to improve the functioning of the health system. Design/Methodology/Approach: The methodology used is descriptive, based on a literature review structured by SWOT tools and the WHO definition of a health system, and it is applied to Portugal. Findings: The strengths and weaknesses in the Portuguese health system are several and varied, and there are some threats and opportunities, too. The improvement of the Portuguese health system and Portuguese health population will have to consider the facts observed here. Originality/Value: This work contributes to the better understanding about the current situation of the Portuguese health system.

Contributo para a compreensão do financiamento da saúde em Portugal: O caso dos cuidados de saúde primários, dos cuidados hospitalares e dos cuidados continuados.

O sistema de saúde português assenta num mix de fontes de financiamento público e privado, tal como acontece em vários países europeus.Dada a sua complexidade, pareceu útil desenvolver um artigo com o objetivo de contribuir para a compreensão do financiamento de saúde em Portugal, tendo em conta as particularidades dos cuidados de saúde primários, dos cuidados hospitalares e ainda dos cuidados continuados.Para esse efeito, foi realizada uma revisão de literatura, com recurso à B-on (Biblioteca do Conhecimento OnlineB-ON - Biblioteca do conhecimento online), através da opção “pesquisa global”, utilizando os descritores financiamento, saúde, Portugal. Como critérios de inclusão foram considerados a existência de um resumo, a disponibilidade integral do artigo online, o período temporal de publicação entre 2005-2015 e o facto de respeitar em concreto o setor da saúde.Os resultados obtidos permitiram a descrição e explicitação das formas de financiamento utilizados no setor da saúde em Portugal, assim como apresentar o modelo de financiamento nos vários níveis de cuidados: primários, hospitalares e continuados.

Where did civil servants go? the effect of an increase in public co-payments on double insured patients.

In Portugal, Civil Servants may have a differential utilization of health services due to their supplementary Health Subsystem (ADSE), which grants them access to health services in the private sector at lower price. We exploit the impact of this double coverage on the demand for Portuguese Public Emergency Departments (ED), following the recent increase in co-payments for public health care services in Portugal.Using detailed ED level data from three different EDs, one for each level of the Portuguese ED care, we rely on a difference-in-differences strategy, under the assumption that both civil servants and National Health Service (NHS) users were targeted by the public co-payment increase, but just the former have a low-cost alternative in the private sector that they can use when prices increase in the NHS.We found that the existence of a low-price alternative in the private sector caused ED demand to decrease among ADSE beneficiaries following a policy that increased co-payments in public NHS hospitals. Specifically, we show that this decrease was only significant for conditions which have arguably the closest substitutes in the private sector – the low and intermediate-severity conditions – and to patients who lived closer to the ED and to whom the co-payment was the largest share of the ED visit cost.These findings cast some concerns over the equity of the Portuguese Health System, since civil servants increasingly opt out from public health services but must co-fund both the ADSE and the NHS.

Health governance in a context of crisis - the perspective of efficiency and effectiveness in the Portuguese health system

<p>The financial and economic crisis from 2008 has<br />a great impact in welfare states, notably in one<br />of their fundamental pillars – health. In Portugal,<br />the total spending on health reached 10.1% of<br />GDP in 2008 and will increase in view of the<br />current panorama. The objective of this study is<br />to analyze the health policies and the Portuguese<br />health system, in a context of economic, financial<br />and social crisis, in the light of the speeches of<br />policy-makers and experts about the processes<br />of governance and contingency measures,<br />considering dimensions of analysis efficiency and<br />effectiveness. In the dimension of effectiveness,<br />measures have been pointed out for protecting<br />the most vulnerable, for the empowerment of<br />citizens, for reduction of inequalities and for the<br />protection and promotion of health. Finally, in<br />the dimension of efficiency, there are important<br />measures to cut off expenditure, of mobilization<br />of financial resources, in the rationalization of<br />resources and services and in professional and<br />organizational development. In theoretical<br />domains of risk and uncertainty, we see through<br />the speeches of policy-makers and experts, that<br />these are domains for the exercise of policies<br />on critical governance processes, determined<br />by identified sources of insecurity, processes of<br />public debate and in terms of policy dispute.</p>

Hospitals and the Public-Private Combination in the Portuguese Health System

The Portuguese health system has been characterized by the existence of a constant relationship between public and private sector, both in providing and financing health care. In recent decades, the private sector increased their responsiveness of care, extending the engagement in the relationship with the public sector. This relationship stems from the legal framework set out in the law, developing agreements, conventions and more recently through the model of public-private partnerships. In hospital network, this new dynamic relationship contributed, in the last two decades, to accentuate the mixed characteristics of the system, through a clear strengthening of the private component in the hospital network, particularly by investing in differentiated units.

Principais Desafios na Saúde

Os sistemas de saúde estão submetidos a grande pressão por fatores externos e internos, os quais exigem um processo de adaptação constante no modelo governance, na organização do sistema e no financiamento para que a sua sustentabilidade e a equidade possam ser asseguradas; a adaptação às novas realidades não pode ser só normativa, tem de ser fundamentalmente organizacional, económica e pragmática.
 Neste artigo são identificadas no sistema de saúde português mudanças que urge levar a cabo; desde logo uma separação clara e transparente dos diferentes papéis que o Estado vem desempenhando com manifesta ineficiência, devendo o Ministério da Saúde centrar a sua atuação primordialmente na regulação forte e efetiva e na contratualização competente, quer junto do setor público quer junto do setor privado, de serviços que lhe compete assegurar mas não necessariamente prestar. Ao mesmo tempo é também urgente a racionalização da oferta com diversificação de formas de gestão de unidades públicas, nomeadamente com parcerias público-privadas que constituem um potente fator de benchmarking para toda a rede e sobre as quais há evidência de aportarem value for money para o Estado.
 Não se conhece com rigor a magnitude da ineficiência no nosso sistema de saúde, mas sabe-se que há enormes ganhos a capturar quer a nível da governance do sistema, quer da arquitetura da oferta, quer da melhoria de performance das unidades prestadoras.

The Future of the Portuguese Health System.

The Portuguese health system has considerable strengths and an impressive track record of success, but is facing severe challenges due to increasing demand and restricted funding. Its continuing success will depend on how citizens and clinicians respond to these challenges as well as on a clear vision for the future and good collective leadership from health professionals, politicians and others in wider society.