Avaliação da Rede de Atenção às Urgências e Emergências na Assistência ao Infarto Agudo do Miocárdio à Liz da Teoria Donabediana

Abstract

This dissertation aimed to evaluate the effectiveness of the Emergency Care Network in the assistance provided to acute myocardial infarction, based on Donabedian’s theory structured in the dimensions of structure, process, and outcomes. It is an evaluative study, with a qualitative and descriptive approach, conducted through the analysis of secondary data extracted from the Department of Informatics of the Unified Health System, the National Registry of Health Establishments, and the State Health Plan of Bahia. The timeframe covered the period from 2013 to 2023, enabling the analysis of a decade of network evolution through indicators of coverage, access, care processes, and outcomes related to acute myocardial infarction. The object of study is part of the cardiovascular line of care, defined as a priority by the National Policy for Emergency Care due to the high mortality of ischemic heart diseases and the timedependent condition of acute myocardial infarction. The choice of this condition as a tracer event was based on its epidemiological relevance and the possibility of measuring objective indicators of the network’s response. The theoretical model adopted was Donabedian’s structure–process–outcome triad, which allows the articulation of available material and organizational conditions, the way services are delivered, and the effects generated on the population’s health, composing a comprehensive evaluation of the network’s effectiveness. The results revealed both advances and weaknesses. In the dimension of structure, the presence of bases of the Mobile Emergency Care Service, Emergency Care Units, and referral hospitals was identified, although unevenly distributed, which highlighted important care gaps. Shortages of intensive care unit beds and coronary care units, along with the concentration of hemodynamic services in Salvador, compromised territorial equity. Regarding care processes, the gradual incorporation of clinical protocols, the implementation of risk classification, and the regulatory role of the mobile emergency service contributed to improving the network’s response. However, failures persisted in the integration between care points, heterogeneous response times, limited availability of pre- and in-hospital thrombolysis, the absence of primary angioplasty in the territory, and reduced articulation with primary health care. These factors compromise the comprehensiveness of care and the full achievement of effectiveness. In terms of outcomes, a paradox was observed: the Northeast Regional Health District presented lower hospital morbidity rates for acute myocardial infarction and, simultaneously, mortality rates also lower than the state average. These findings, although they may indicate resolvability in certain cases, raise the hypothesis of underreporting and flaws in the recording of health information systems, pointing to the need to improve data quality. The critical analysis demonstrated that, although the objectives were achieved by mapping the network, measuring indicators, and discussing its effectiveness structural and organizational limitations persist, revealing a mismatch between the normative design of the policy and its implementation in the territories. In the Northeast Regional Health District of Bahia has achieved significant advances but has not yet reached full effectiveness. More than the existence of isolated services or indicators, effectiveness translates into the ability to provide timely, integrated, and resolutive responses to the population’s needs. The evaluation carried out reaffirms the importance of evaluative research as a scientific and political tool, essential to strengthening the Unified Health System as a public, universal, and equitable system.