摘要：Objectives. We compared the incidence of recurrent or fatal cardiovascular disease in patients using Brazil’s government-run Family Health Program (FHP) with those using non-FHP models of care. Methods. From 2005 to 2010, we followed outpatients discharged from city public hospitals after a first ever stroke for stroke recurrence and myocardial infarction, using data from all city hospitals, death certificates, and outpatient monitoring in state-run and private units. Results. In the follow-up period, 103 patients in the FHP units and 138 in the non-FHP units had exclusively state-run care. Stroke or myocardial infarction occurred in 30.1% of patients in the FHP group and 36.2% of patients in non-FHP care (rate ratio [RR] = 0.85; 95% confidence interval [CI] = 0.61, 1.18; P = .39); 37.9% of patients in FHP care and 54.3% in non-FHP care (RR = 0.68; 95% CI = 0.50, 0.92; P = .01) died. FHP use was associated with lower hazard of death from all causes (hazard ratio [HR] = 0.58; P = .005) after adjusting for age and stroke severity. The absolute risk reduction for death by all causes was 16.4%. Conclusions. FHP care is more effective than is non-FHP care at preventing death from secondary stroke and myocardial infarction. Most strokes occur in low- and middle-income countries, where the disability-adjusted life-years and hospitalization costs are high. 1,2 As the young populations of these countries age, stroke incidence and burden will probably rise. 3,4 Therefore, it is important to evaluate and implement the best strategy for the primary and secondary prevention of stroke and myocardial infarction in these countries. 5 In Brazil, the state-run health care system is universal. Three quarters of the population use it exclusively and one quarter uses both public and private health services. In 1994 the Unified National Health System was reorganized to prioritize a new model of care called the Family Health Program (FHP). 6 The Brazilian FHP model is centered on a family and community approach in which a multiprofessional team (consisting of a doctor, a nurse, an auxiliary nurse, and 4–6 community health workers) provides comprehensive care. 6,7 Family health care teams are assigned to specific geographical areas and populations of 600 to 1000 families and are responsible for permanent and systematic follow-up of a given number of families living in a circumscribed area and for establishing ties of commitment and shared responsibility. 6–8 The program was expanded from a minor pilot program covering very few selected areas in 1994 to a nationwide large-scale program in 2006. Today, the FHP covers more than 100 million people in more than 90% of Brazilian municipalities. 6–8 From 1996 to 2004, in Brazilian cities where the FHP had intermediate city population coverage (30.0%–69.9% coverage, or > 70.0% coverage and duration of < 4 years), the adjusted infant mortality rate decreased 16%. In cities with complete city coverage (coverage of > 70.0% and duration of > 4 years), it decreased by 22%. 9 The remaining population is covered by the traditional model of primary care. In this model, created before the FHP, a multidisciplinary team, composed of general practitioners, gynecologists, pediatricians, dentists, nurses, and auxiliary nurses, works on demand. This is still the most prevalent model in the country and, unlike the FHP model, has no community health workers and no limits to the number of families it can care for. 9,10 To our knowledge, there is no clear evidence of the effectiveness of Brazil’s FHP model for preventing secondary stroke and myocardial infarction. 10 Joinville is an industrial city in southern Brazil, where two thirds of the citizens are covered exclusively by the state-run health care system and the remaining third by both state-run and private care, mostly through employers. We have shown that the incidence, mortality, and 30-day case fatality of first ever stroke decreased in Joinville by one third from 1995 to 2005. 11 To determine what happens to those patients when they return to the state-run health units, we compared stroke recurrence, myocardial infarction, and death among patients surviving their first ever stroke who were followed in the FHP units with those followed in non-FHP units.
