Revista Panamericana de Salud Pública/Pan American Journal of Public Health

In 2000, the Pan American Health Organization (PAHO), with technical assistance from the U.S. Centers for Disease Control and Prevention (CDC), initiated the project to establish injury surveillance systems in EDs with the goal of advancing injury epidemiology and prevention capacity in Latin America. Colombia, El Salvador, and Nicaragua were selected for the initial pilot surveillance systems, which were designed to enhance the ability of select hospitals to monitor injury trends and promote appropriate prevention interventions. The project also sought to increase injury awareness among health officials and personnel from other agencies.

Establecimiento de sistemas de vigilancia de lesiones en Colombia, El Salvador y Nicaragua (2000–2006)

La Organización Panamericana de la Salud (OPS), en colaboración con los Centros para el Control y la Prevención de Enfermedades (CDC) de los Estados Unidos de América, estableció en 2000 sistemas para la vigilancia de lesiones en Colombia, El Salvador y Nicaragua. Estos sistemas, basados en los servicios hospitalarios de emergencia, formaron parte de un proyecto piloto fundamentado en las guías para la vigilancia de lesiones, desarrolladas por la Organización Mundial de la Salud (OMS) y los CDC. Los objetivos de este proyecto eran evaluar la utilidad de las guías de la OMS/CDC, crear mecanismos apropiados para la vigilancia de lesiones en los tres países, promover intervenciones preventivas adecuadas e integrar la prevención y el control de lesiones en proyectos nacionales de salud pública. En este artículo se describe el proyecto piloto de la OPS/CDC y se resaltan los principios más importantes y las lecciones aprendidas durante sus seis años de funcionamiento (2000–2006). Entre las principales recomendaciones se encuentran la integración de la vigilancia de las lesiones en las unidades de epidemiología e información existentes en los ministerios de salud, la recogida de los datos importantes exclusivamente, la garantía de monitoreos y evaluaciones adecuados y la adopción de las prácticas que han demostrado ser más efectivas para el entrenamiento de personal y la diseminación de información.

Objective. This article describes the characteristics of violence-related injury (VRI) cases presenting at emergency departments (EDs) in Brazil and compares circumstances for assaultrelated and self-inflicted cases.
Methods. The study is cross-sectional. The data describe cases seen in September 2006 in 62 EDs, representing all 26 states and the Federal District. A total of 4 835 case records were analyzed. Basic statistical tabulations were complemented by logistic regression analysis to assess potential associations between type of violence (assault or self-harm) and multiple factors.
Results. Males comprised 72.8% of cases while those aged 20 to 29 comprised 35.4%. Alcohol use was reported or suspected in 42.7% of cases, more commonly among males. Assault victims comprised 91.4% of cases versus self-inflicted injuries, which accounted for 8.6%. Threefourths of the assault victims were male, while over half of the self-inflicted injury victims were female. The leading mechanism for assaults was physical force/blunt objects (46.2%), whereas poisoning was the predominant mechanism for self-inflicted injuries (71.4%). Younger females were significantly more likely to have been victims of self-inflicted injuries than younger males, while younger males were more likely to have been victims of assault; this finding is more pronounced in cases where alcohol use was reported. Self-inflicted injuries were significantly more likely to occur in residences, while assaults were more likely to occur away from home.
Conclusion. These results can improve understanding of the scope and characteristics of VRIs in Brazil (and thus contribute to national injury prevention efforts), and help identify areas for future research.

Lesiones relacionadas con la violencia en los servicios de emergencia de Brasil

Objetivos. Se describen las características de los casos de lesiones relacionadas con la violencia (LRV) que se presentan en los servicios de emergencia en Brasil y se comparan las circunstancias de los casos relacionados con asaltos y los autoinfligidos.
Métodos. En este estudio de corte transversal se describen los casos atendidos en septiembre de 2006 en 62 servicios de emergencia de 26 estados y el Distrito Federal. Se analizaron 4 835 casos por medio de tabulaciones estadísticas básicas y se evaluó mediante análisis de regresión logística la posible asociación entre los tipos de violencia (asalto o lesión autoinfligida) y diversos factores.
Resultados. De los casos, 72,8% eran hombres y 35,4% tenían entre 20 y 29 años. Se informó o sospechó del consumo de bebidas alcohólicas en 42,7% de ellos, más frecuentemente en hombres. De los casos, 91,4% eran víctimas de asaltos y 8,6% de lesiones autoinfligidas. Tres cuartas partes de las víctimas de asaltos eran hombres y la mitad de las lesiones autoinfligidas fueron en mujeres. El principal mecanismo de asalto fue la fuerza física/objetos romos (46,2%), mientras que el veneno fue el mecanismo predominante en las lesiones autoinfligidas (71,4%). Las mujeres jóvenes presentaron una probabilidad significativamente mayor de haber sufrido lesiones autoinfligidas que los hombres jóvenes, mientras que estos tuvieron una mayor probabilidad de haber sido víctimas de asaltos, especialmente cuando se informó de consumo de alcohol. Las lesiones autoinfligidas tuvieron una probabilidad significativamente mayor de ocurrir en el hogar, mientras que los asaltos fueron más probables fuera de casa.
Conclusiones. Estos resultados pueden ayudar a comprender mejor el alcance y las características de las LRV en Brasil —y así contribuir a los esfuerzos nacionales de prevención de lesiones— y a identificar nuevas áreas de investigación.

Emergency care for victims of accidents and violence in Brazil

Objective. To analyze positive results, challenges, limitations, and potential benefits associated with the Brazilian Policy for the Reduction of Morbidity and Mortality due to Accidents and Violence (PNRMAV) with regard to hospital emergency and urgent care services.
Methods. From 2004–2007, a study was carried out in four Brazilian state capitals and the Federal District. The following areas were evaluated: the availability of standard practices for managing victims of accident or violence; availability and quality of adult and pediatric intensive care beds; patient management training for health care professionals; communication among the health care areas to provide better care to victims; and structure and organization of hospital services. The study included an exploratory stage, fieldwork, analysis, and dissemination of data. Both quantitative (absolute and relative frequencies) and qualitative methods (analysis of interactions between explicit and inferred information from statements and field records) were employed in the analysis.
Results. The study revealed positive results from the implementation of PNRMAV. The following focal areas were identified: (1) the need to invest in the response capacity of primary care services, (2) the importance of strengthening and promoting the emergency and urgent care network, (3) the importance of investing in appropriate equipment and of planning maintenance so that availability is not impacted, and (4) the need to invest in continuing education for health care professionals.
Conclusions. The partial success obtained with PNRMAV shows that it is possible to include the topic of violence and accidents in the public health agenda and to implement life-promoting strategies at different levels.

Objetivo. Analisar os êxitos, lacunas, problemas e potencialidades da aplicação da Política Nacional de Redução de Morbimortalidade por Acidentes e Violências (PNRMAV) no Brasil quanto à atenção hospitalar de emergência e urgência.
Métodos. De 2004 a 2007, uma pesquisa foi realizada em quatro capitais e no Distrito Federal. Os seguintes aspectos foram investigados: existência de padronização de condutas de atendimento às vítimas de acidentes e violências; oferta e adequação de leitos de terapia intensiva (adulta e pediátrica); capacitação dos profissionais para o atendimento; existência de articulação intersetorial para melhor atendimento às vítimas; e estruturação e organização dos serviços de atendimento hospitalar. A operacionalização incluiu uma fase exploratória, trabalho de campo, análise e divulgação dos dados. Para a análise, foram utilizados métodos quantitativos (freqüências simples e relativas) e qualitativos (análise de interações entre conteúdos manifestos e inferências de conteúdos latentes nos depoimentos e anotações de campo).
Resultados. O estudo revelou resultados positivos associados à implantação da PNRMAV e permitiu identificar os seguintes pontos de atenção: 1) necessidade de investimento na resolutividade dos serviços de atenção básica, 2) importância de se fortalecer e articular a rede de urgência e emergência, 3) relevância dos investimentos em equipamentos adequados e sua manutenção no ritmo exigido pelos atendimentos e 4) necessidade de investimentos na formação permanente de profissionais.
Conclusões. Os sucessos parciais alcançados pela implantação da PNRMAV mostram que é possível incluir o tema da violência e dos acidentes na pauta da saúde pública e atuar com estratégias em diferentes níveis a favor da vida.

Control of cervical cancer in Colombia: the perspective of the health system

Objectives. To characterize the health system stakeholder’s perspective on the basics of the political, economic, and sanitary context, as well as the ways in which control activities are being realized in four of Colombia’s health departments.
Methods. This was a qualitative study of four Colombian health departments chosen for their differing cervical cancer mortality rates and their planned disease control efforts (Boyacá, Caldas, Magdalena, and Tolima). Semistructured interviews were conducted of health care managers, insurance coordinators, and public and private health institutions at the departmental and municipals levels. Focus groups comprised of professionals from health insurance companies and health care services providers were convened. Data analysis was based on the grounded theory with open codes related to the roles of health care managers, insurance companies, and heath care services provided. The technical reports were compared to the testimonies of interviewees.
Results. Thirty-eight interviews and 14 focus groups (70.9% response rate) were conducted and 12 technical reports reviewed. Cervical cancer is not perceived to be a public health priority. Interest centers on the flow of financial resources within the health system. Findings indicated unsatisfactory communication among the stakeholders and no consensus on the subject. Planning is limited to meeting the status quo. Staffing is inadequate. Cases with positive outcomes are lost to follow-up due to the fragmentation that results from affiliation with different health care systems.
Conclusions. The financial situation, normative planning, and the challenges of decentralization affect the skill-building, at-risk coverage, and the control activities needed for effective screening programs. What is needed is an integrated, more efficiently organized program in which all the health system stakeholders participate.

Objetivo. Caracterizar, desde la perspectiva de los actores del sistema de salud, los elementos del contexto político, económico y sanitario, así como la forma en que se articulan las actividades para el control del cáncer cervicouterino en cuatro departamentos de Colombia.
Métodos. Estudio cualitativo en cuatro departamentos colombianos seleccionados por sus diferentes niveles de mortalidad por cáncer cervicouterino y de organización de las actividades de control de esta enfermedad (Boyacá, Caldas, Magdalena y Tolima). Se realizaron entrevistas semiestructuradas a funcionarios, directores de aseguradoras y de instituciones de salud públicas y privadas a niveles departamental y municipal. Se conformaron grupos focales con profesionales de las empresas aseguradoras y prestadoras de servicios. El análisis de la información se basó en la teoría fundamentada con codificaciones abiertas relacionadas con las funciones de las direcciones de salud, de las empresas aseguradoras y las acciones de los servicios de salud. Los informes técnicos se contrastaron con los testimonios.
Resultados. Se realizaron 38 entrevistas y se trabajó con 14 grupos focales (70,9% de respuesta) y 12 informes técnicos. El cáncer cervicouterino no es percibido como una prioridad de la salud pública. El interés se centra en el flujo de dinero dentro del sistema. No se encontró una adecuada articulación entre los actores y no hay rectoría en el tema. La planificación se limita al cumplimiento de las normas. Los recursos humanos son inadecuados. No hay seguimiento de los casos positivos por la fragmentación de la población según su afiliación al sistema de salud.
Conclusiones. La orientación financiera, la planificación normativa y las dificultades de la descentralización afectan al desarrollo de las competencias, la cobertura de la población de alto riesgo y las actividades de control necesarias para el adecuado funcionamiento de los programas de tamizaje. Se requiere un programa integrado y mejor organizado en el que participen los diferentes actores del sistema de salud.

Objectives. To describe the clinical experience of a Guatemalan pediatric HIV clinic and referral center, and fill the gap in literature available on pediatric HIV in Guatemala, a country facing a growing HIV epidemic.
Methods. Analyses were performed on data available from the clinical databases maintained by the Clínica Familiar Luis Ángel García within the Hospital General San Juan de Dios in Guatemala City, Guatemala.
Results. From January 1997–June 2006, a total of 536 children (individuals under 13 years of age) were registered at the clinic, 54% of them female. At the initial visit, 241 were known to be HIV infected, while 295 were known to have been exposed to HIV, but were of undetermined infection status. Of the 295 with undetermined status, serostatus was determined in 173, and 57 (33%) were HIV positive. The patients came from all 24 departments of Guatemala, but the majority (64%) was from Guatemala City. Most had perinatal exposure; three patients had been sexually exposed to HIV (all male); and the mode of infection could not be determined for six children. In the cohort of children whose infection status was initially undetermined, the provision of antiretroviral (ARV) medication (both pre- and neonatal), in addition to Cesarean section, was associated with an odds ratio of 0.06 for HIV infection (P < 0.001) when compared to children who had no interventions. Highly active antiretroviral therapy (HAART) was administered to 167 HIV-infected children. There were 44 known deaths in this cohort; no deaths occurred among the children who were not infected.
Conclusions. Pediatric HIV/AIDS is present in all parts of Guatemala. Programs to prevent mother to child transmission and to provide appropriate treatment to families living with HIV/AIDS must be a public health priority.

Experiencia de una clínica pediátrica para el VIH en la Ciudad de Guatemala

Objetivos. Describir la experiencia de una clínica y centro de referencia pediátrico para el VIH en Guatemala y llenar el vacío existente en la literatura científica sobre la infección pediátrica por el VIH en ese país, donde se enfrenta una creciente epidemia por el VIH.
Métodos. Se analizaron los datos disponibles en la base de datos clínicos de la Clínica Familiar Luis Ángel García del Hospital General San Juan de Dios, Ciudad de Guatemala, Guatemala.
Resultados. Entre enero de 1997 y junio de 2006 en la clínica se registraron 536 menores de 13 años; 54% de los cuales eran niñas. En la visita inicial se sabía que 241 estaban infectados por el VIH y que 295 habían estado expuestos a ese virus aunque su diagnóstico era indeterminado. De estos, se determinó el estatus serológico de 173, de los cuales 57 (33%) resultaron positivos al VIH. Los pacientes procedían de los 24 departamentos de Guatemala, pero la mayoría (64%) era de la Ciudad de Guatemala. La mayoría de los pacientes había estado expuestos al VIH por la vía perinatal; tres pacientes (todos varones), por la vía sexual y no se pudo determinar la vía de infección de seis niños. En la cohorte de niños con diagnóstico inicial indeterminado, el tratamiento antirretroviral (tanto pre como posnatal) junto con el nacimiento por cesárea se asociaron con una razón de posibilidades (odds ratio) de tener la infección por el VIH de 0,06 (P < 0,001) en comparación con los niños sin estas intervenciones. El tratamiento antirretroviral de gran actividad (HAART) se administró a 167 niños infectados por el VIH. Se registraron 44 muertes en esta cohorte, ninguna en los niños sin infección.
Conclusiones. La infección pediátrica por VIH/sida está presente en todos los departamentos de Guatemala. Los programas para evitar la transmisión de madre a hijo y brindar el tratamiento adecuado a las familias que viven con VIH/sida son una prioridad de salud pública

Deficiencies in evaluating health care reforms in the 1990s in Latin America

Some of the recurring themes seen on health-sector reform agendas of Western countries (those at the center as well as those on the periphery) over the last decade have been: the debate over new ways of organizing health systems, with sights set on achieving greater efficiency and quality; redefining health care benefit packages and services to better distribute health resources; and incorporating market mechanisms into the health care environment to better respond to expectations of health care consumers.

The fundamental purpose of this article is to analyze certain concepts that define and explain the origin of the 1990s health care reforms in Latin America and to refute some of the more important principles, such as: the belief that improving the functional efficiency of the health care system alone would improve the health of the population; the excessive concern with the administrative and structural aspects of health systems without a discussion of the underlying theoretical models; the idea that access, in and of itself, can guarantee “equity in health”; and lastly, the undo emphasis that was placed on individual “risk factors” as the cause of all illness.

Al final de los años ochenta y principios de los noventa, en la mayoría de los países occidentales se generalizó un movimiento de reformas sanitarias que autores como Almeida (1) ubican en la tercera generación de reformas en el sector salud del siglo XX,2 estrechamente relacionado con la “agenda post-welfare” y la tendencia internacional de reforma del Estado que puso sobre la mesa de discusión temas como el papel del Estado y del mercado en el sector sanitario, la descentralización, la privatización y la concesión de mayor capacidad de elección a los “consumidores” de los servicios de salud.

Fraud in the health systems of Chile: a detection model

Objectives. To develop a model for detecting cases of organized fraud in Chile based on data from the legal forms for medically authorized leave (formulario legal de licencia médica curativa–MAL) and to establish the relevance of this data to fraud detection.
Methods. A binomial logistic regression model was employed using four variables from the MAL form, a national requirement for illness-related work absences: the number of legal absences taken by a single person, the number of days authorized by the prescribing doctor, the total cost per illness, and a dichotic variable reflecting whether or not the diagnosis is one that can be proven. The analysis involved 4 079 MAL forms that had been submitted in 2003 to a private health provider and of which 356 were already identified as fraudulent by a panel of medical fraud experts.
Results. The model successfully identified 99.71% of the fraudulent medical authorizations and 99.86% of the non-fraudulent, according to the criteria of the panel of fraud experts. Three of the variables employed had statistically-significant independent predictive power. The positive predictive value of the proposed model was 98.59%, while its negative predictive value was 99.97%.
Conclusions. The binomial logistic model that was developed uses four variables that are common to all MAL forms in use by Chile’s public as well as private insurers, permitting separation of fraudulent from non-fraudulent requests to be more accurate, more timely, and at a cost lower that of an expert panel.

Objetivos. Desarrollar un modelo para detectar casos de fraude planificado en Chile a partir de los datos contenidos en los formularios de licencia médica curativa (LMC) y establecer la contribución relativa de esos datos a su detección.
Métodos. Se aplicó un modelo de regresión logística binominal a partir de cuatro variables contenidas en el formulario legal de LMC exigido nacionalmente para justificar las ausencias al trabajo por motivos de enfermedad: el número de licencias médicas asignadas a una misma persona, el número de días de licencia médica otorgados por el médico tratante, el monto total a pagar por la enfermedad y una variable dicotómica que refleja si el diagnóstico es comprobable o no. Se analizaron 4 079 LMC presentadas el año 2003 a una institución privada de salud previsional, de las cuales 356 estaban ya clasificadas como fraudulentas por un panel de médicos expertos en fraude.
Resultados. El modelo logró identificar correctamente 99,71% de las licencias médicas fraudulentas y 99,86% de las no fraudulentas según el criterio del panel de expertos en fraude. Tres de las variables empleadas presentaron un poder predictivo independiente estadísticamente significativo. El valor predictivo positivo del modelo propuesto fue de 98,59%, mientras el valor predictivo negativo fue de 99,97%.
Conclusiones. El modelo logístico binomial desarrollado, basado en cuatro variables de uso universal en los formularios de LMC utilizados por todas las entidades aseguradoras de Chile, tanto públicas como privadas, permite discriminar de forma precisa y más rápidamente y con menor costo que los paneles de expertos las solicitudes fraudulentas de las no fraudulentas.

Antiretroviral drug supply in Argentina: National Program to Combat Human Retroviruses, AIDS, and STDs

Objectives. To evaluate the supply cycle of antiretroviral (ARV) drugs, overseen by the National Program to Combat Human Retroviruses, AIDS, and STDs, through its order fulfillment indicators, and to obtain input from supply chain stakeholders.
Methods. A study was carried out from April–September 2005 in the pharmacies of two hospitals in Rosario, Argentina, involving both a quantitative analysis of indicators and secondary sources and a qualitative evaluation using semistructured interviews.
Results. The indicators reveal the impact that interruptions in ARV supply stream from the Program (central level) have and the overstocking that takes place at the pharmacies (local level) to manage the shortages. Changes in ARV treatment account for over 50% of the prescriptions. Fulfillments fall short of the reference value. The interviewees shared possible strategies for overcoming the communication gaps between levels, for building-up stock, for guaranteeing availability, and for shortening waiting times; reached informal agreements to deal with the lack of policies and the shortage of staff; acknowledged the challenges facing the jurisdictions (central, intermediate, and local/community); and recognized local efforts to improve management.
Conclusions. These challenges could be the starting point for building teams to work on effectively decentralizing the entire supply chain and allowing the Program to fulfill its much-needed oversight role.

Objetivos. Evaluar el circuito de suministro de antirretrovirales (ARV) dentro del Programa Nacional de Lucha contra los Retrovirus del Humano, SIDA y ETS, mediante indicadores de desempeño, y recuperar la perspectiva de actores involucrados en el circuito de provisión. Se busca mejorar las acciones programáticas satisfaciendo las necesidades de los pacientes. Métodos. En el servicio de farmacia de dos hospitales de Rosario, Argentina, de abril a septiembre de 2005 se llevó a cabo una investigación evaluativa con un abordaje cuantitativo, mediante indicadores y basado en fuentes secundarias, y otro cualitativo, con entrevistas semiestructuradas. Resultados. Los indicadores revelan el impacto de las interrupciones en la provisión de ARV desde el Programa (nivel central) y la acumulación de stock en el nivel local para paliar esas faltas. Los cambios de tratamiento con ARV representan más de 50% de las prescripciones. El cumplimiento en el retiro de ARV se aleja del valor de referencia. Los entrevistados describieron estrategias alternativas para superar dificultades de comunicación entre niveles, acumular stock, garantizar disponibilidad y acortar tiempos de espera; se establecieron acuerdos informales ante la falta de normativas y la escasez de recursos humanos; las instancias jurisdiccionales (central, intermedia y local o municipal) suman dificultades, y se reconocen esfuerzos del nivel local para mejorar la gestión. Conclusiones. Estos hallazgos pueden ser el punto de partida para la construcción de propuestas que involucren equipos de trabajo afectados en el circuito de provisión en su totalidad, a fin de lograr una descentralización efectiva, en congruencia con el papel rector que le corresponde necesariamente al Programa.

Identifying predictive factors for therapy nonadherence among hypertensive, older adults from a community in southern Chile

Objective. To identify the predictive factors associated with therapy nonadherence among hypertensive older adults, based on functional dependency, memory disorders, self-perceived wellbeing, abuse, and depression in an area of southern Chile.
Methods. A quantitative, exploratory study of a sample of 211 hypertensive, older adults (29.1% of those being treated by the cardiovascular program at the Centro de Salud Familiar San Pedro, in the province of Concepción, del Bío Bío region, Chile). Seven instruments were applied: Pfeiffer’s short mental status questionnaire, Yesavage’s geriatric depression scale, the elder abuse screening scale, the morale scale of the Philadelphia Geriatric Center, the health behavior scale, the Lawton assessment of instrumental activities of daily living (ADL), and the Katz ADL index. Following an analysis of the important components, latent variables were identified.
Results. Two latent variables were identified: social connectedness—measured by the variables depression, abuse, and social satisfaction—and autonomy—measured by the variables mental health and ability to perform basic and instrumental ADLs. These latent variables accounted for 39.7% and 20.7% of nonadherence to therapy, respectively.
Conclusions. The latent variables proposed here can be used as predictive factors for therapy nonadherence in elderly adults with arterial hypertension. Causes of nonadherence to therapy cannot be assessed solely at health care centers; but rather, an understanding of the home environment is needed and treatment should be adapted according to the needs that exist there.

Objetivo. Identificar factores de predicción del incumplimiento terapéutico en adultos mayores hipertensos a partir de su dependencia funcional, trastornos de memoria, percepción de bienestar, maltrato y depresión en una región del sur de Chile.
Métodos. Estudio cuantitativo exploratorio en una muestra de 211 adultos mayores hipertensos (29,1% de los atendidos en el Programa Cardiovascular del Centro de Salud Familiar San Pedro, en la provincia de Concepción, Región del Bío Bío, Chile). Se aplicaron siete instrumentos: el cuestionario abreviado de Pfeiffer para el estado mental, la escala de Yesavage para la depresión geriátrica, la escala de maltrato senil, la escala moral del Centro Geriátrico de Filadelfia, la escala de conductas en salud y las escalas de Lawton y Katz para medir la capacidad de realizar actividades instrumentales y básicas de la vida diaria, respectivamente. Mediante el análisis de componentes principales se definieron variables latentes.
Resultados. Se determinaron dos variables latentes: vinculación con el medio —medida a partir de las variables depresión, maltrato y satisfacción con el medio— y autonomía —medida a partir de las variables estado mental y capacidad para realizar actividades instrumentales y básicas—. Estas variables latentes explicaron 39,7% y 20,7% del incumplimiento terapéutico, respectivamente.
Conclusiones. Las variables latentes propuestas pueden emplearse como factores de predicción del incumplimiento terapéutico de los adultos mayores con hipertensión arterial. Las causas del incumplimiento terapéutico no pueden medirse solamente en los establecimientos de salud, es necesario conocer el entorno primario en el hogar y adecuar la atención sanitaria a partir de las necesidades que allí se detecten.

Simulation model for estimating the cancer care infrastructure required by the public health system

Objective. To develop a simulation model using public data to estimate the cancer care infrastructure required by the public health system in the state of São Paulo, Brazil.
Method. Public data from the Unified Health System database regarding cancer surgery, chemotherapy, and radiation therapy, from January 2002–January 2004, were used to estimate the number of cancer cases in the state. The percentages recorded for each therapy in the Hospital Cancer Registry of Brazil were combined with the data collected from the database to estimate the need for services. Mixture models were used to identify subgroups of cancer cases with regard to the length of time that chemotherapy and radiation therapy were required. A simulation model was used to estimate the infrastructure required taking these parameters into account.
Results. The model indicated the need for surgery in 52.5% of the cases, radiation therapy in 42.7%, and chemotherapy in 48.5%. The mixture models identified two subgroups for radiation therapy and four subgroups for chemotherapy with regard to mean usage time for each. These parameters allowed the following estimated infrastructure needs to be made: 147 operating rooms, 2 653 operating beds, 297 chemotherapy chairs, and 102 radiation therapy devices. These estimates suggest the need for a 1.2-fold increase in the number of chemotherapy services and a 2.4-fold increase in the number of radiation therapy services when compared with the parameters currently used by the public health system.
Conclusion. A simulation model, such as the one used in the present study, permits better distribution of health care resources because it is based on specific, local needs.

Objetivo. Desenvolver um modelo de simulação para estimar a infraestrutura necessária à assistência oncológica no sistema público de saúde do Estado de São Paulo, Brasil, tendo por base dados de domínio público.
Método. Dados de domínio público do Sistema Único de Saúde referentes à produção assistencial de janeiro de 2002 a janeiro de 2004 para cirurgia oncológica, quimioterapia e radioterapia foram utilizados para estimar o número de casos de câncer no Estado. Os percentuais de cada procedimento terapêutico observados no Registro Hospitalar de Câncer foram combinados com os dados da produção assistencial para estimar um perfil de necessidade de serviço. Modelos de mistura foram utilizados para identificar subgrupos de casos de câncer com tempos de utilização diferenciados para quimioterapia e radioterapia. Um modelo de simulação foi empregado para estimar a infraestrutura necessária de acordo com os parâmetros definidos.
Resultados. O modelo estimou a necessidade de cirurgia para 52,5% dos casos de câncer, radioterapia para 42,7% e quimioterapia para 48,5%. Os modelos de mistura identificaram dois subgrupos de casos com tempo médio de utilização diferenciado para radioterapia e quatro subgrupos para quimioterapia. Com esses parâmetros, a infraestrutura estimada foi de: 147 salas de cirurgia, 2 653 leitos cirúrgicos, 297 poltronas de quimioterapia e 102 equipamentos de terapia por radiação. Essas estimativas indicam a necessidade de aumentar os serviços de quimioterapia em 1,2 e os serviços de radioterapia em 2,4 vezes em relação aos parâmetros de programação utilizados atualmente no sistema público de saúde.
Conclusão. A utilização de modelos dessa natureza propicia uma melhor distribuição dos recursos em saúde, uma vez que toma como base a necessidade assistencial regional.