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

Document Type : Original Article

Authors

1 School of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil

2 Graduate Program in Epidemiology, TelehealthRS Project, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil

3 Universidade de Caxias do Sul (UCS), Caxias do Sul, Brazil

4 Community Health Services, Grupo Hospitalar Conceição, Porto Alegre, Brazil

5 School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil

Abstract

Background 
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.
 

Methods 
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.
 

Results 
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.
 

Conclusion 
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.

Keywords


  1. Instituto Nacional de Câncer (INCA). Estimativa 2020. Incidência de câncer no Brasil. 2020. https://www.inca.gov.br/sites/ufu.sti.inca.local/files/media/document/estimativa-2020-incidencia-de-cancer-no-brasil.pdf. Accessed September 22, 2020.
  2. Rabeneck L, Lansdorp-Vogelaar I. Assessment of a cancer screening program. Best Pract Res Clin Gastroenterol. 2015;29(6):979-985. doi:1016/j.bpg.2015.09.009
  3. World Health Organization (WHO). Cancer Control Knowledge into Action. WHO Guide for Effective Programmes. Early Detection. 2007. https://apps.who.int/iris/bitstream/handle/10665/43743/9241547338_eng.pdf;jsessionid=766DBB85136951641C7264DB7337A40F?sequence=1. Accessed September 22, 2020.
  4. Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database Syst Rev. 2013;2013(6):CD001877. doi:1002/14651858.CD001877.pub5
  5. Holme Ø, Bretthauer M, Fretheim A, Odgaard-Jensen J, Hoff G. Flexible sigmoidoscopy versus faecal occult blood testing for colorectal cancer screening in asymptomatic individuals. Cochrane Database Syst Rev. 2013(9):CD009259. doi:1002/14651858.CD009259.pub2
  6. Maia MN, da Silva RP, dos Santos LP. A organização do rastreamento do câncer do colo uterino por uma equipe de Saúde da Família no Rio de Janeiro, Brasil. Rev Bras Med Fam Comunidade. 2018;13(40):1-10. doi:5712/rbmfc13(40)1633
  7. Derchain S, Teixeira JC, Zeferino LC. Organized, population-based cervical cancer screening program: it would be a good time for Brazil now. Rev Bras Ginecol Obstet. 2016;38(4):161-163. doi:1055/s-0036-1582399
  8. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Diretrizes brasileiras para o rastreamento do cancer do colo do utero. Coordenação de Prevenção e Vigilância. Divisão de Detecção Precoce e Apoio à Organização de Rede, editor. Ministério da Saúde; 2016. p. 114. http://bvsms.saude.gov.br/bvs/controle_cancer. Accessed September 22, 2020.
  9. Rodrigues DCN, Freitas-Junior R, Rahal RMS, et al. Temporal changes in breast cancer screening coverage provided under the Brazilian National Health Service between 2008 and 2017. BMC Public Health. 2019;19(1):959. doi:1186/s12889-019-7278-z
  10. da Silva Teixeira L, Araújo Neto LA. Still controversial: early detection and screening for breast cancer in Brazil, 1950-2010s. Med Hist. 2020;64(1):52-70. doi:1017/mdh.2019.76
  11. Lima MS, de Abreu Costa Brito É, Siqueira HFF, et al. Trends in cervical cancer and its precursor forms to evaluate screening policies in a mid-sized Northeastern Brazilian city. PLoS One. 2020;15(5):e0233354. doi:1371/journal.pone.0233354
  12. da Silva ST, Martins MC, de Faria FR, Cotta RM. [Combating smoking in Brazil: the strategic importance of government actions]. Cien Saude Colet. 2014;19(2):539-552. doi:1590/1413-81232014192.19802012
  13. Ministério da Saúde. e-Gestor. Atenção Básica. Informação e Gestão da Atenção Básica. Cobertura da Atenção Básica. https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaAB.xhtml. Accessed September 22, 2020.
  14. Andrade MV, Coelho AQ, Xavier Neto M, de Carvalho LR, Atun R, Castro MC. Transition to universal primary health care coverage in Brazil: analysis of uptake and expansion patterns of Brazil's Family Health Strategy (1998-2012). PLoS One. 2018;13(8):e0201723. doi:1371/journal.pone.0201723
  15. Chueiri PS, Gonçalves MR, Hauser L, et al. Reasons for encounter in primary health care in Brazil. Fam Pract. 2020;37(5):648-654. doi:1093/fampra/cmaa029
  16. Gusso GD. Diagnóstico de demanda em Florianópolis utilizando a Classificação Internacional de Atenção Primária: 2a edição (CIAP-2) [dissertation]. São Paulo: Faculdade de Medicina, Universidade de São Paulo (USP); 2009. doi:11606/T.5.2009.tde-08032010-164025
  17. Norman AH, Tesser CD. [Quaternary prevention in primary care: a necessity for the Brazilian Unified National Health System]. Cad Saude Publica. 2009;25(9):2012-2020. doi:1590/s0102-311x2009000900015
  18. Jung M. Breast, prostate, and thyroid cancer screening tests and overdiagnosis. Curr Probl Cancer. 2017;41(1):71-79. doi:1016/j.currproblcancer.2016.11.006
  19. Jacklyn G, Bell K, Hayen A. Assessing the efficacy of cancer screening. Public Health Res Pract. 2017;27(3):2731727. doi:17061/phrp2731727
  20. Shieh Y, Eklund M, Sawaya GF, Black WC, Kramer BS, Esserman LJ. Population-based screening for cancer: hope and hype. Nat Rev Clin Oncol. 2016;13(9):550-565. doi:1038/nrclinonc.2016.50
  21. Rech MRA, Hauser L, Wollmann L, et al. [Primary health care performance in Brazil and association with the More Doctors physician recruitment programCalidad de la atención primaria de salud en Brasil y relación con el Programa Más Médicos]. Rev Panam Salud Publica. 2018;42:e164. doi:26633/rpsp.2018.164
  22. Shi L, Starfield B, Xu J. Validating the adult primary care assessment tool. J Fam Pract. 2001;50(2):161.
  23. Harzheim E, de Oliveira MM, Agostinho MR, et al. Validação do instrumento de avaliação da atenção primária à saúde: PCATool-Brasil adultos. Rev Bras Med Fam Comunidade. 2013;8(29):274-284. doi:5712/rbmfc8(29)829
  24. Stopa SR, Szwarcwald CL, de Oliveira MM, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude. 2020;29(5):e2020315. doi:1590/s1679-49742020000500004
  25. Duro LN, Assunção MC, da Costa JS, Santos IS. Desempenho da solicitação do perfil lipídico entre os setores público e privado. Rev Saude Publica. 2008;42(1):82-88. doi:1590/s0034-89102008000100011
  26. Instituto Nacional do Câncer José Alencar Gomes da Silva (INCA). Ficha técnica de indicadores das ações de controle do câncer do colo do útero. https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//fichatecnicaindicadorescolo14.pdf. Accessed September 22, 2020. Published 2014.
  27. S. Preventive Services. Task Force. Final Recommendation Statement. Cervical Cancer: Screening. 2018. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screening. Accessed April 7, 2021.
  28. Dickinson J, Tsakonas E, Conner Gorber S, et al. Recommendations on screening for cervical cancer. CMAJ. 2013;185(1):35-45. doi:1503/cmaj.121505
  29. Everett T, Bryant A, Griffin MF, Martin-Hirsch PP, Forbes CA, Jepson RG. Interventions targeted at women to encourage the uptake of cervical screening. Cochrane Database Syst Rev. 2011;2011(5):CD002834. doi:1002/14651858.CD002834.pub2
  30. Migowski A. [Interpretation of the new guidelines for breast cancer early detection in Brazil]. Cad Saude Publica. 2016;32(8):e00111516. doi:1590/0102-311x00111516
  31. Klarenbach S, Sims-Jones N, Lewin G, et al. Recommendations on screening for breast cancer in women aged 40-74 years who are not at increased risk for breast cancer. CMAJ. 2018;190(49):E1441-E1451. doi:1503/cmaj.180463
  32. S. Preventive Services. Task Force. Final Recommendation Statement. Breast Cancer: Screening. 2016. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening. Accessed April 7, 2021.
  33. Instituto Nacional do Câncer (INCA). Câncer de ovário - versão para Profissionais de Saúde. https://www.inca.gov.br/tipos-de-cancer/cancer-de-ovario/profissional-de-saude. Accessed September 22, 2020. Published 2018.
  34. Canadian Task Force on Preventive Health Care (CTFPHC). Screening for ovarian cancer: US preventive services task force reaffirmation recommendation statement. https://canadiantaskforce.ca/guidelines/appraised-guidelines/ovarian-cancer/. Accessed April 7, 2021. Published 2013.
  35. S. Preventive Services. Task Force. Final Recommendation Statement. Ovarian Cancer: Screening. 2018. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/ovarian-cancer-screening. Accessed April 7, 2021.
  36. Ministério da Saúde. Nota Técnica conjunta n.º 001/2015. https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//nota-tecnica-saude-do-homem-ms.pdf. Accessed September 22, 2020. Published 2015.
  37. Bell N, Connor Gorber S, Shane A, et al. Recommendations on screening for prostate cancer with the prostate-specific antigen test. CMAJ. 2014;186(16):1225-1234. doi:1503/cmaj.140703
  38. S. Preventive Services. Task Force. Final Recommendation Statement. Prostate Cancer: Screening. 2018. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening. Accessed April 7, 2021.
  39. Ilic D, Neuberger MM, Djulbegovic M, Dahm P. Screening for prostate cancer. Cochrane Database Syst Rev. 2013(1):CD004720. doi:1002/14651858.CD004720.pub3
  40. Ministério da Saúde. Cadernos de Atenção Básica. Estratégias para o cuidado da pessoa com doença crônica : o cuidado da pessoa tabagista. http://189.28.128.100/dab/docs/portaldab/publicacoes/caderno_40.pdf. Accessed September 22, 2020. Published 2015.
  41. World Health Organization (WHO). Tobacco Free Initiative (TFI). Policy recommendations for smoking cessation and treatment of tobacco dependence. https://www.who.int/tobacco/resources/publications/tobacco_dependence/en/. Accessed September 22, 2020.
  42. S. Preventive Services. Task Force. Final Recommendation Statement. Interventions for tobacco smoking cessation in adults, including pregnant persons. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions. Accessed April 7, 2021. Published 2021.
  43. Marcano Belisario JS, Bruggeling MN, Gunn LH, Brusamento S, Car J. Interventions for recruiting smokers into cessation programmes. Cochrane Database Syst Rev. 2012;12(12):CD009187. doi:1002/14651858.CD009187.pub2
  44. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev. 2017;3(3):CD001292. doi:1002/14651858.CD001292.pub3
  45. Sivaram S, Majumdar G, Perin D, et al. Population-based cancer screening programmes in low-income and middle-income countries: regional consultation of the International Cancer Screening Network in India. Lancet Oncol. 2018;19(2):e113-e122. doi:1016/s1470-2045(18)30003-2
  46. Tomazelli JG, Migowski A, Ribeiro CM, de Assis M, de Abreu DMF. Avaliação das ações de detecção precoce do câncer de mama no Brasil por meio de indicadores de processo: estudo descritivo com dados do Sismama, 2010-2011. Epidemiol Serv Saude. 2016;26(1):61-70. doi:5123/s1679-49742017000100007
  47. Freitas-Junior R, Rodrigues DC, Corrêa RD, Peixoto JE, de Oliveira HV, Rahal RM. Contribution of the Unified Health Care System to mammography screening in Brazil, 2013. Radiol Bras. 2016;49(5):305-310. doi:1590/0100-3984.2014.0129
  48. Corrêa CSL, Pereira LC, Leite ICG, Fayer VA, Guerra MR, Bustamante-Teixeira MT. Breast Cancer screening in Minas Gerais: assessment of data from information health systems of the Brazilian National Health System. Epidemiol Serv Saude. 2017;26(3):481-492. doi:5123/s1679-49742017000300006
  49. Ribeiro CM, Silva GAE. Assessment of the production of cervical cancer care procedures in the Brazilian National Health System in 2015. Epidemiol Serv Saude. 2018;27(1):e20172124. doi:5123/s1679-49742018000100004
  50. Vale DB, Menin TL, Bragança JF, Teixeira JC, Cavalcante LA, Zeferino LC. Estimating the public health impact of a national guideline on cervical cancer screening: an audit study of a program in Campinas, Brazil. BMC Public Health. 2019;19(1):1492. doi:1186/s12889-019-7846-2
  51. Instituto Nacional do Câncer (INCA). Boletim ano 9, n.o 1, Janeiro/Junho de 2018. Monitoramento das ações do controle dos Cânceres de colo de útero. https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//informativo_deteccao_precoce_numero1_2018.pdf. Accessed September 22, 2020. Published 2018.
  52. Lopes VAS, Ribeiro JM. Cervical cancer control limiting factors and facilitators: a literature review. Cien Saude Colet. 2019;24(9):3431-3442. doi:1590/1413-81232018249.32592017
  53. Basu P, Nessa A, Majid M, Rahman JN, Ahmed T. Evaluation of the National Cervical Cancer Screening Programme of Bangladesh and the formulation of quality assurance guidelines. J Fam Plann Reprod Health Care. 2010;36(3):131-134. doi:1783/147118910791749218
  54. Parham GP, Mwanahamuntu MH, Kapambwe S, et al. Population-level scale-up of cervical cancer prevention services in a low-resource setting: development, implementation, and evaluation of the cervical cancer prevention program in Zambia. PLoS One. 2015;10(4):e0122169. doi:1371/journal.pone.0122169
  55. Instituto Nacional do Câncer (INCA). Boletim ano 8, nº 2, julho/dezembro 2017. Monitoramento das ações de controle do câncer de próstata. http://www.saude.df.gov.br/wp-conteudo/uploads/2018/03/Informativo-Câncer-de-Próstata-2017.pdf. Accessed September 22, 2020. Published 2017.
  56. Santiago LM, Luz LL, da Silva JF, Mattos IE. [Prevalence and factors associated with conducting screening tests for prostate cancer in the elderly in Juiz de Fora in the state of Minas Gerais, Brazil]. Cien Saude Colet. 2013;18(12):3535-3542. doi:1590/s1413-81232013001200010
  57. Amorim VM, de Azevedo Barros MB, César CL, Goldbaum M, Carandina L, Alves MC. [Factors associated with prostate cancer screening: a population-based study]. Cad Saude Publica. 2011;27(2):347-356. doi:1590/s0102-311x2011000200016
  58. Morgan DJ, Dhruva SS, Coon ER, Wright SM, Korenstein D. 2018 update on medical overuse. JAMA Intern Med. 2019;179(2):240-246. doi:1001/jamainternmed.2018.5748
  59. Peer RF, Shabir N. Iatrogenesis: a review on nature, extent, and distribution of healthcare hazards. J Family Med Prim Care. 2018;7(2):309-314. doi:4103/jfmpc.jfmpc_329_17
  60. Ministério da Saúde. Pesquisa Nacional de Saúde. https://biblioteca.ibge.gov.br/visualizacao/livros/liv91110.pdf. Accessed September 22, 2020. Published 2014.
  61. Kahende JW, Loomis BR, Adhikari B, Marshall L. A review of economic evaluations of tobacco control programs. Int J Environ Res Public Health. 2009;6(1):51-68. doi:3390/ijerph6010051

Articles in Press, Corrected Proof
Available Online from 30 August 2021
  • Receive Date: 30 September 2020
  • Revise Date: 24 April 2021
  • Accept Date: 24 July 2021