To increase healthcare quality in a sustainable and equitable fashion is a major
challenge in the contemporary world. Country governments need to continuously search
for
creative and intelligent solutions to align in a balanced way the multiple health
subsystems with the needs and expectations of the patient and community, and such
solutions have to be viable and sustainable. Developed countries use science to assess
the quality of the health care provided and to generate information to improve the
outcomes
1
. Science-based
public policies are the current paradigm in those countries. In Brazil, however, the
ideological viewpoint seems to prevail.
"Outcomes research", "health service research" and "implementation science" comprise
a
significant part of the themes related to the scientific study of health care quality
and its relation to the health system
1
, but still lack disclosure and institutional incentives to thrive in
Brazil. Those areas are usually devoted to systematically and methodically assess
various aspects related to the structuration of health systems, their outcomes for
the
patient and community, physician-patient relationship, the ways such outcomes can
be
improved, and how innovations should be implemented. Out of the three, the "outcomes
research" stands out, because it investigates the outcomes of health care focused
by the
perspective that directly interests patients and society
1
.
Scrutinizing the quality of the Brazilian health system
Since the Brazilian 1998 Federal Constitution (Constitution of the Citizen) was
signed and the Brazilian National Unified Health Care System (SUS) was created in
1990, the right to integral, universal, equalitarian and free access to health
services of quality has been granted to all Brazilians. The State would have to
finance, provide and operate the infrastructure necessary to fulfill the Law
8.080/1990. The constitutional recognition that health is a universal right was a
substantial ideological advance. On paper, the public health model idealized for
Brazil has become an example to the world. Approximately 75% of Brazilians are
estimated to depend on the SUS for health care, while the remaining Brazilians have
private complementary coverage.
If the objective is to generate relevant information to guide decision making
regarding public policies on health, we should systematically dedicate ourselves to
scientifically assess the health care outcomes of SUS. However, after 25 years from
SUS implantation, there is little scientific evidence, especially that representing
the continental country Brazil is, on the final health care outcomes of SUS. For
example, representative data on post-acute myocardial infarction mortality,
reperfusion treatment rate or hospital readmission rate in 30 days are not
available. Moreover, little is known about the disparities of the health care
outcomes between the SUS and the private health care system.
The consolidation and construction of an equitable, safe, responsive, accessible and
efficient health system require the careful and scientific examination of the SUS
and the Brazilian complementary health system at national level. The recent
initiative of the Brazilian Society of Cardiology encouraging national registries,
although still timid in transforming Brazilian public health, should be
praised
2
.
DATASUS could play a role in surveilling the quality of the health care outcomes of
the major Brazilian health problems. However, the unsatisfactory quality of data
input and the lack of studies nationally validating DATASUS as a reliable data bank
are usually limiting factors to its scientific use.
In the United States, administrative data from Medicare have been used in several
studies on monitoring and surveillance of health care macro-indicators in the major
cardiovascular pathologies
3-5
, significantly helping knowing the
outcomes of the health care provided to North-Americans aged 65 years and older.
Health care outcomes as a scientific theme
The concept of the imperative need to constantly assess the real-world health care
outcomes to continuously improve the health system has been crystallized in the
end-result idea by Ernst Codman (1910)
6
. According to Codman, the end-result idea requires the results
to be constantly assessed and possible solutions to improve them to be constantly
considered.
The theoretical basis of "outcomes research" was later refined by Donabedian, who
has
proposed a conceptual model
7
in
which the quality of the health system could be inferred by approaching the
following three domains: structure, process and outcomes. The "outcome" domain is
the one that best captures the quality of the health care that interests patients
and society.
In 1998, the term "outcomes research" entered the scientific terminology in a
classical publication in the journal Science. As defined by Clancy
and Eisenberg, "outcomes research" investigates the effects of medical interventions
and policies on the outcomes that directly interest individuals and
society
8
.
Ten years later, when the American Heart Association launched the journal
Circulation Cardiovascular Quality and Outcomes, edited by
Krumholz and associates, "outcomes research" was definitely recognized as an
important area of cardiovascular investigation, endorsing the emergent field of
biomedical research
9
.
Examples of studies on the quality of cardiological care in Arquivos Brasileiros
de Cardiologia
The journal Arquivos Brasileiros de Cardiologia is the major vehicle
of Brazilian cardiology and represents the Brazilian Society of Cardiology. We
reviewed original articles published in the Arquivos Brasileiros de
Cardiologia in the last two years on quality of health care, aiming at
providing examples of studies that could contribute to and impact on the Brazilian
health care outcomes.
To make our investigation more comprehensive, we subdivided the theme "quality of
health care" into some subthemes that directly interest outcomes research and others
that specifically interest Brazil, such as the focus on SUS
1
(Table 1). We intended to assess neither the quality of the study
published nor its potential impact on generating guideline recommendations. Some
studies served more than one category.
Table 1
Original articles on quality of care in Arquivos Brasileiros de
Cardiologia
Examples of studies*
Safety
Eficácia e Segurança de Stents Eluidores de
Drogas no Mundo Real: Acompanhamento de 8 Anos
10
Temporal line of care, access and
responsiveness of the system
Implantação da Linha de Cuidado do Infarto
Agudo do Miocárdio no Município de Belo
Horizonte
11
Efetividade de um Protocolo Assistencial para
Redução do Tempo Porta-Balão da Angioplastia Primária
12
Variability in health care practice
None
Effectiveness
Estratégia Antitrombótica nos Três Meses
Iniciais após Implante de Bioprótese Valvar Cardíaca
13
Cost
Itinerário de Investigação do Paciente
Coronariano do SUS em Curitiba, São Paulo e Incor - Estudo
IMPACT
14
Disparity
Evolução de Indicadores Socioeconómicos e da
Mortalidade Cardiovascular em três Estados do Brasil
15
Patient-centered care /autonomy / shared decision
making
None
Institutional results
Experiência Inicial de Dois Centros Nacionais
no Implante de Prótese Aórtica Transcateter
16
Registries on specific diseases
Registro Brasileiro das Síndromes Coronárias
Agudas (ACCEPTf
Estudo BREATHE -1 Registro Brasileiro de
Insuficiência Cardíaca
17
Comportamento da Síndrome Coronariana Aguda.
Resultados de um Registro Brasileiro
18
Focus on SUS
Itinerário de Investigação do Paciente
Coronariano do SUS em Curitiba, São Paulo e Incor - Estudo
IMPACT
14
Although no systematic quantitative assessment was performed, we identified a
notorious scarcity of investigation directly approaching the theme "quality of the
health care" provided by the Brazilian health system.
Challenges and opportunities
Our search, restricted to the Arquivos Brasileiros de Cardiologia,
suggests that Brazil needs to increase its scientific production capable of guiding
public policies in the cardiovascular setting, where the use of imported science has
critical limitation and can bias decision making. Systematically knowing the
Brazilian health care outcomes is essential to elaborate and prioritize the agenda
of regional and national public policies.
We have a long way to go and at least the following two very well-defined challenges
to face if we bet on science to support decision making regarding public policies
on
health: to produce high-level national science representing the quality of Brazilian
health care; and to convince federal, state and municipal authorities that science
is a fundamental tool to guide decision making on the implantation of public
policies.
That requires substantial investment: 1) in the intellectual formation of specialized
researchers; 2) in improving the quality of DATASUS as a data bank for research in
all Brazilian states; 3) in the creation, structuration and consolidation of
cooperative research groups; and 4) in the continuous encouragement of the national
scientific production.
For the Brazilian cardiovascular scientific community, especially younger
researchers, this gap in the Brazilian science can represent a great opportunity to
embrace a research line that can substantially impact on and benefit Brazil and
Brazilians.