Avaliação do programa de terapia nutricional enteral domiciliar do Distrito Federal no ano de 2022 e elaboração de material educativo para a população

Abstract

Introduction: Nutritional therapy consists of a set of nutritional therapeutic procedures that employ specific methods and techniques with the aim of maintaining or recovering individuals at risk of malnutrition or with nutritional problems. It is indicated for cases of special dietary needs, whether temporary or permanent, caused by metabolic or physiological changes in the food intake pathway or in the biological use of nutrients. Home Enteral Nutrition Therapy (HENT) is characterized by the provision of enteral nutrition at home, allowing reintegration into the family nucleus, discharge from hospital and hospital bed turnover. Thus, it is an integral part of home care, an element of continuity of health care after discharge from hospital. The State Department of Health of the Federal District has a program for the provision of formulas for special purposes called the Home Enteral Nutrition Therapy Program (HENTP). The program serves patients with an indication for HENT via tube or ostomy and specific cases of oral supplementation. Although the importance of HENTP is recognized, in the experience of the profession and after research in documents related to HENTP and in scientific databases, a lack of literature that focuses on the population's access to the program and enteral diets was observed. There is a lack of research focusing on estimating the time to execute the steps of the process, so that there is an estimate for the population of how long the process lasts on average, and how long HENTP users need to wait until they are allowed to take the enteral diets. Objectives: General: to identify the influence of factors on the waiting time until receiving enteral formulas. Specific objective 1: to characterize the steps related to user access to the HENTP, estimate the time interval between each step of the registration process in the program, as well as the total time elapsed between the first request for inclusion of the patient in the HENTP and the withdrawal of the formulas at the Home Nutrition Center, in addition to identifying factors that are associated with the time elapsed between the request for registration of the patient in the program and the beginning of the receipt of enteral formulas. Specific objective 2: to outline the sociodemographic, epidemiological and nutritional profile of the population studied. Specific objective 3: to develop an information channel for the population, with general information about the HENTP, guidelines on scheduling the withdrawal of enteral formulas on the Agenda DF website, on the management of enteral diets at home, storage and handling care, as well as care with feeding devices (nasoenteral tube, gastrostomy or jejunostomy). Method: Descriptive, quantitative study, with retrospective collection of administrative and clinical data from public sources, from the Alphalinc systems, the electronic information system of the Health Department of the Federal District, and physical files stored in the Home Nutrition Center. 439 first-time registration processes of patients between 18 and 59 years old in 2022 were analyzed. The project was approved by the Research Ethics Committee. As the study involves secondary and retrospective data, a waiver of the application of the Free and Informed Consent Form (FICF) was requested. Due to the time between approval and development of the research, a partial report was sent to the Research Ethics Committee with some preliminary results. For the 1st objective, which resulted in article 1, the following were calculated: the time interval between the preparation and signing of the social, nutritional, and medical reports; the time interval between the signing of the last professional report issued to the nutrition management sector and the document dispatching the inclusion of the participant in the HENTP; the time interval between the signing of the first report and the document of inclusion in the HENTP; the time interval between the date of signing of the last professional report and the date of the patient's inclusion in the program; the total time from the first report issued until the withdrawal of the enteral diet by the participant; and the time between the entry into the program and the withdrawal of the product by the participant. All of these metrics were calculated through the difference in days between each of the dates. These variables were treated as continuous, being summarized with median and interquartile range (25th percentile and 75th percentile) due to the non-normality observed in most of the data. The data were analyzed using the R 4.2.2 program (R Core Team, Vienna, Austria), with an alpha of 5%. For the second objective, which resulted in article 2, epidemiological, social and health data were collected. The variables collected were divided into 2 main groups. The first group included socioeconomic data, consisting of variables such as age, sex, place of residence, region of origin of the reports from the doctor, social service and nutrition, type of housing, participation in social assistance programs, need for a caregiver, among others. The second group included epidemiological and nutritional data, encompassing clinical diagnosis, feeding route, types of devices used for feeding, nutritional diagnosis according to BMI, among others. The clinical diagnosis data were initially grouped, for study purposes, into 11 groups according to the international classification of diseases (ICD-10): diseases of the circulatory system; neoplasms; endocrine, nutritional and metabolic diseases; diseases of the nervous system; diseases of the respiratory system; diseases of the digestive system; diseases of the skin and subcutaneous tissue; diseases of the genitourinary system; injuries, poisonings, and some consequences of external causes; congenital malformations, deformities and chromosomal anomalies; infectious and parasitic diseases. To enable statistical tests to analyze the association between the qualitative variables clinical diagnosis and sex, clinical diagnosis and feeding route, nutritional diagnosis and sex, the clinical diagnoses were regrouped into 5 categories, combining clinical affinity and ensuring adequate sizes of each group. The new diagnostic categories after regrouping were: Chronic noncommunicable diseases (diseases of the circulatory system; neoplasms and endocrine diseases; nutritional and metabolic diseases), Neurological and musculoskeletal diseases (diseases of the nervous system), Infectious, inflammatory and immunological diseases (diseases of the respiratory system; infectious and parasitic diseases; diseases of the skin and subcutaneous tissue and diseases of the genitourinary system), Gastrointestinal and metabolic diseases (diseases of the digestive system), External causes and malformations (injuries, poisoning and some consequences of external causes and congenital malformations, deformities and chromosomal anomalies). The Statistical Package for the Social Sciences (SPSS) version 20 was used for data analysis. Descriptive statistics were performed, with frequency measures of the variables, in addition to the chi-square test to assess associations between variables. For the continuous variables age and BMI, the median and interquartile range (25th percentile and 75th percentile) values were obtained due to the non-normality observed in the data. Categorical variables were summarized with counts and proportions (n, %). Qualitative variables were classified into classes for analysis purposes so that their quantification was possible. For the third objective, which resulted in a technical and technological product, educational material was created for the population, consisting of a channel on the YouTube website called “Information on the Home Enteral Nutrition Therapy Program of the Federal District (HENTP)”, where three videos were inserted, two with instructions on how the program works, how to schedule and withdraw enteral diets, based on the Manual of the Enteral Nutrition Therapy Program of the Federal District. For the third video, on care with enteral diets, the Home Nutrition Therapy Guide of the University of São Paulo and the Manual of Care for Enteral Nutrition Therapy at Home of the State of Pará were used as a basis. Products developed: Product 1 (Manuscript) - Assessment of the adult population's access to the Enteral Nutrition Therapy Program of the Federal District (HENTP) in 2022. The study aimed to identify factors that may interfere with patients' waiting time to receive enteral formulas. To this end, it sought to characterize and estimate the time elapsed between the steps involved in the process, as well as the total time, and identify factors that may be associated with an increase or reduction in this time. The study allowed the identification of factors that may interfere with patients' waiting time for the HENTP registration process and also that interfere with the withdrawal of enteral formulas and products. It was observed that there are factors related to the process and factors related to the social and health conditions of patients. Delays in signing reports and restitution of processes were factors related to the process that interfered with the time. Regarding patients, the factors that interfered with the process time included the need for a caregiver, type of housing, route and feeding device. It was also found that patients or guardians take a relatively long time to collect the formulas and that in 33% of cases the formulas were not collected after authorization for registration in HENTP. The study provided unprecedented data regarding the time spent in each stage of the patient inclusion process in HENTP, data that can serve as a basis for further studies on how to optimize the times between stages, think of solutions to improve the service in order to deliver efficiency results and reduce waiting times to the population. Product 2 (Manuscript) - Profile of patients in the home enteral nutritional therapy program of the Federal District in 2022. The study aimed to outline a socioeconomic, epidemiological, and nutritional profile of adult patients registered with HENTP in 2022, in order to understand this population group. The study found that the patients served by HENTP in 2022 were, for the most part, from the most populated administrative regions of the Federal District, with lower gross monthly household income, less access to health plans, and with a majority of the population in a situation of risk or social vulnerability. When evaluating the total sample, the majority of patients were female, using oral feeding, diagnosed with neoplasms, underweight, and functional independence. When analyzing by gender, a prevalence of underweight, chronic non-communicable diseases, enteral feeding, and a high degree of functional dependence was found in males. In females, the nutritional diagnosis of obesity, diseases of the digestive system, oral feeding and functional independence prevailed. Product 3 (Technical Scientific Product) – YouTube channel entitled “Information on the Home Enteral Nutrition Therapy Program of the Federal District (HENTP)”, where 3 videos were inserted, the first two with instructions to users on how the program works, how to schedule and withdraw formulas and the third with information on care with enteral nutrition. This project is aligned with the research line of Quality in Healthcare for Adults and the Elderly. Conclusions: This study provided unprecedented data on the time between the steps required to register patients in the Home Enteral Nutrition Therapy Program of the Federal District. These data can serve as a basis for new studies on the efficiency of the steps of the process, with the possibility of seeking improvements in this system, to promote optimization of the resources used for the benefit of the community that depends on this service. The research was original and innovative in nature, in the sense that no study was found in the literature that had focused on the time spent in the steps of the registration process and the factors that influence it, both in HENTP and in other HENT programs in the country, serving as an initial framework for studies focused on the topic at both the local and national levels. These data can be useful for the strategic planning of HENTP, providing important information for the management of processes, with the search for solutions to optimize each step, bringing more efficiency to the program. The results of the research contribute to the scientific community by providing updated information on the sociodemographic, epidemiological and health profile of the adult population, which has fewer studies when compared to the pediatric and elderly populations. The fact that this study focused on the Federal District is also relevant to the academic community, since it makes it possible to compare the characteristics and health conditions between states and cities, in order to identify where public policies should act with greater emphasis to promote equity in services. The technical and technological product (TTP) developed aims to contribute to the dissemination of relevant information about HENTP, as well as guidance on dietary care and enteral tubes. The focus of the TTP was to disseminate information that is easier for the population to understand, so that it can be more easily understood by people of all levels of education. With more information on monitoring the process and guidance on the steps to schedule the collection of products, it is expected that there will be a reduction in the number of formulas not collected from the Home Nutrition Center.