Estudo da avaliação e das adequações de tratamento para a doença arterial coronariana em pacientes do Sistema Único de Saúde de Belo Horizonte

Abstract

Introduction: With the increased incidence and the prevalence of cardiovascular diseases and the development and implementation of new treatments, particularly for coronary arterial disease, it is necessary to investigate the accuracy of referrals to cardiology procedures. Based on the observed high expenditures with cardiac surgeries in the city of Belo Horizonte and considering the need of improving its regulation, in 2003, the local public health system (Municipal Health Secretary of Belo Horizonte SMSA/SUS/BH), reorganized the flow of patients, established a partnership with Hospital das Clínicas da UFMG (HC/UFMG), and created the Reference Ambulatory for High Complexity in Cardiology of HC/UFMG-SMSA/SUS-BH. Objective: To describe the results of the assessments made by doctors auditors and the "expert panel" of cardiac revascularization procedures and assess the main predictors of a statement deemed appropriate by the "expert panel." Methods: This is a transversal study of a sample of 165 patients evaluated in the Reference Ambulatory for High Complexity in Cardiology of the HC/UFMG-SMSA/SUS-BH from May to November 2007. From each patient, we collected clinical data, which was recorded in a standardized protocol, the auditing doctors evaluation of the adequacy of the requesting doctors referrals, copies of coronariography movies and functional test results (ergometric test, stress echocardiogram, and/or myocardial cintilography). The protocol and the exams were identified with a number and given to two cardiologist revisers named A and B, who were blind to the auditor's referral evaluation. The evaluation of the two cardiologists was called expert panel .Results: In the studied sample, 95 (57.6%) requests were for coronary angioplasty (ICP) and 70 (42.4%) for myocardial revascularization surgery (CABG). According to the auditors evaluation, in 165 evaluations, 126 (76.4%) procedures requested by the assistant doctor were considered appropriate and 39 (23.6%) were considered inappropriate. In relation to the expert panel, the assistant doctors referrals were classified as appropriate in 89 cases (53.9%) and 76 (46.1%) were considered inappropriate. The degree of agreement between cardiologists A and B before the consensus by Kappa statistical analysis was 0.66 (0.54-0.77, CI 95%). After multivariate analysis, predictors were considered an appropriate indication for revascularization procedure of the following: angina, prior CABG, CABG request, ischemia on noninvasive testing and left anterior descending artery (LAD) coronary disease. Conclusion: Although the Reference Ambulatory for High Complexity in Cardiology has been operating since 2003, about one fourth of the myocardial revascularization procedures requested were considered inappropriate by the ambulatory auditing doctors and nearly half of them did not meet the referral criteria of an independent evaluation (expert panel") according the evaluation by two cardiologists based the current guidelines. In assessing the "expert panel" at the request of CABG clinical and characteristics such as angina, ischemic evaluation and left anterior descending artery (LAD), as well as previous history of CABG were considered predictive of an indication rated as appropriate.