Evaluation of the longitudinality between users and residency programs in Family and Community Medicine in a region of the municipality of Rio de Janeiro, BrazilAbstract
Primary Health Care (PHC) in Brazil has become stronger in recent decades, thus increasing the demand for workers in the area. Using a cross-sectional design (n=492), this study aimed to evaluate the longitudinal tie of adult users and their relationship with the Family and Community Medicine Residency Program (Programa de Residência em Medicina de Família e Comunidade - PRMFC) in a region of the municipality of Rio de Janeiro from the perspective of adult users. To this end, we used the reduced version of the Primary Care Assessment Tool (PCATool) questionnaire, combined with the extended version of the “longitudinality” attribute. This study was conducted in two family clinics, one participating in the PRMFC for over 10 years and the other non-participatory. The overall PHC score for the entire study population was 5.63 [4.56; 5.80]. Comparatively, the performance in the family clinic with PRMFC was higher (6.32 [6.12; 6.53]) than that with no residency program (4.94 [4.70; 5. 19]). Regarding longitudinality, the former also obtained a higher score (7.02 [6.81; 7.23]) when compared to the latter (5.43 [5.17; 5.68]). The results of this study suggest to administrators that the PRMFC can be a useful tool for improving the quality of services through the qualification of Family Doctors and, thus, calls for investments in the area.
Key words: Primary Health Care; Longitudinality; Health assessment; Rio de Janeiro
Resumo
A Atenção Primária à Saúde (APS) no Brasil se fortaleceu nas últimas décadas e assim a demanda por trabalhadores do setor. Com delineamento transversal (n=492), objetivamos avaliar o vínculo longitudinal dos usuários adultos e a sua relação com o Programa de Residência em Medicina de Família e Comunidade (PRMFC) em uma área do município do Rio de Janeiro sob a ótica dos usuários adultos. Para tal, utilizamos o questionário Primary Care Assessment Tool versão reduzida, combinado com a versão estendida do atributo “longitudinalidade”. A pesquisa foi realizada em duas Clínicas da Família, uma unidade participante do PRMFC há mais de 10 anos e outra não participante. O escore geral da APS para toda a população estudada foi 5,63 [4,56; 5,80]. Comparativamente, o desempenho da Clínica da Família com PRMFC foi superior (6,32 [6,12; 6,53]) ao da unidade sem o programa (4,94 [4,70; 5,19]). Quanto à longitudinalidade, a primeira também obteve escore superior (7,02 [6,81; 7,23]) ao da segunda (5,43 [5,17; 5,68]). Os resultados deste estudo apontam para gestores que o PRMFC pode ser uma ferramenta útil para a melhoria da qualidade dos serviços através da qualificação dos Médicos de Família, e, para tal, demanda investimentos na área.
Palavras-chave: Atenção Primária à Saúde; Longitudinalidade; Avaliação em saúde; Rio de Janeiro
Resumen
La Atención Primaria de Salud (APS) en Brasil se ha fortalecido en las últimas décadas, junto con la demanda de trabajadores del sector. Se trata de un estudio transversal (n = 492) con el objetivo de evaluar el vínculo longitudinal entre los usuarios adultos y su relación con el Programa de Residencia en Medicina Familiar y Comunitaria (PRMFC) en un área de la ciudad de Río de Janeiro, desde la perspectiva de los usuarios adultos. Para ello, se utilizó el cuestionario Primary Care Assessment Tool, versión reducida, combinado con la versión ampliada del atributo “longitudinalidad”. La investigación se realizó en dos clínicas de familia, una participante en el PRMFC desde hace más de diez años y la otra no participante. La puntuación global de la APS para toda la población del estudio fue de 5,63 (4,56; 5,80). En comparación, el rendimiento de la Clínica de la Familia con PRMFC fue superior (6,32 [6,12; 6,53]) al de la unidad sin el programa (4,94 [4,70; 5,19]). En cuanto a la longitudinalidad, la primera también obtuvo una puntuación más alta (7,02 [6,81; 7,23]) que la segunda (5,43 [5,17; 5,68]). Los resultados de este estudio apuntan a que el PRMFC puede ser una herramienta útil para mejorar la calidad de los servicios a través de la cualificación de los médicos de familia, pero para ello es necesario invertir en el área.
Palabras clave: Atención Primaria de Salud; Longitudinalidad; Evaluación en salud; Rio de Janeiro
Introduction
Consolidated at an international conference held at Alma-Ata in 1978, Primary Health Care (PHC) is recognized as a model that provides broader and better access to health systems, and is a means through which to reorganize healthcare systems throughout the world1. In universal healthcare systems, it is the first level of user access to health services, and should be able to care for the most common conditions and resolve most of the health demands of the population2.
To guide the organization of these services, Barbara Starfield defined a set of desirable characteristics for the evaluation of PHC services, along with its essential and derived attributes. Among these is longitudinality, which is the PHC characteristic of being the common source of care for the individual over time, with a relationship established with a doctor, team, or service that is sought when there is a need for care, and the maintenance of this relationship even when there are no immediate health needs. The maintenance of such a partnership is beneficial for the care provided to the users of a healthcare system3.
In Brazil, the implementation of the PHC began in the 1990’s, after the proclamation of the 1988 Constitution and the creation of the Unified Health System (SUS)4. Complying with the organization of this system, the primary sector evolved in a decentralized manner throughout the country, with the municipal management of its planning, resulting in heterogeneous characteristics.
In the municipality of Rio de Janeiro, PHC was characterized by low expansion capacity of the Family Health Strategy (FHS) up to 2009, organized around health centers with specialized doctors5 and with a coverage of only 3.5% by the FHS. In 2009, Medical Care Reforms in PHC (Reforma dos Cuidados em Atenção Primária em Saúde - RCAPS) were implemented, with a plan that facilitated the expansion of PHC services, prioritizing FHS as a model and promoting the administrative and organizational restructuring and reform of the very model of care. That initiative resulted in an expressive increase in population coverage by PHC at the municipal level, passing from the 3.5% coverage in December 2008 to 55% in 2015, as well as in the number of Family Health Teams (FHTs) created, from 128 in 2008 to 958 in 20165.
The period from 2018 to 2020 was a time of setbacks for the model, with new adjustments in healthcare teams, with a decrease in the number of health agents and a 35% decline in terms of FHTs. However, a new effort towards encouraging and expanding PHC was observed in 2021, after yet another change in management. According to data from the e-gestor AB site, regarding the history of PHC coverage, in October 2023, the municipality of Rio de Janeiro had 1,256 teams and a population coverage of nearly 82%.
An increase in PHC coverage led to a demand for more professionals in the area. To address the demand for medical professionals resulting from PHC expansion and to boost the qualification, maintenance, and attraction of professionals, in 2012, the Municipal Health Secretary of Rio de Janeiro (SMS-RJ) began the Family and Community Medicine Residency Program (Programa de Residência em Medicina de Família e Comunidade - PRMFC-Rio) with the purpose of providing qualification to health professionals working with the initiative, as well as strengthening other programs (UFRJ/Fiocruz and UERJ) which already existed in the municipality6.
Considering the relevance achieved by PHC in the Brazilian healthcare system since its creation, the debates regarding its resolutivity and efficiency have been furthered7. This encouraged the search for ways to evaluate the system, aimed at identifying strengths and weaknesses, and serving as a tool to help improve the management structure8. Among the available instruments, the Primary Care Assessment Tool (PCATool) is used by many countries worldwide. It has also been validated nationally, is capable of measuring the degree of orientation for PHC, and is applicable to professionals, managers, and users alike6.
The municipality of Rio de Janeiro is unique in the formulation of this service and has the largest Family and Community Health Residency Program in the country, generating 150 new positions each year, together with an active presence of the residents in the work processes within Family Clinics. Hence, there is a clear need to evaluate the quality of the PHC structures and processes as regards the training of these health professionals.
Evaluations of healthcare services in Rio de Janeiro are still few and far between, especially concerning medical residency. In the literature, two important evaluations were conducted by Harzheim in Rio de Janeiro, using the PCATool, both conducted ten years ago and are in need of updating: the first study, from 2013, used the professional version of the tool, showing better results for specialists in Family and Community Medicine (FCM)9; the other, from 2014, conducted with a large sample10. Medical residency was not considered in these studies.
Therefore, the current study aims to evaluate the dimension of the longitudinal connection and its relationship with residency in FCM as regards Planning Area 3.1 of the municipality of Rio de Janeiro, from the perspective of adult users. This study also aims to characterize the profile of the interviewees according to sex, age group, race/color of skin, marital status, and relationships with longitudinality, as well as examine the evaluation of the users by the PCATool in relation to the overall score obtained in each unit.
Materials and methodology
A population survey was conducted, with adult users of two PHC facilities from Planning Area 3.1, in the municipality of Rio de Janeiro: Felippe Cardoso Family Clinic (CFFC) and Nilda Campos Family Clinic (CFNC). The criteria for inclusion was that the users had to have been registered at either family clinic and be 18 years of age or older.
The size of the simple random sample (SRS) was calculated to compare the degree of orientation towards PHC (overall score from 0 to 10), of the two family clinics. The calculations were conducted using a 95% confidence interval (95% CI), and a precision (d) of 6.5% of the estimates to be calculated, considering that, in addition to the scores of the questionnaire generated by the PCATool, there would be several other questions with frequencies (prevalence) that must also be calculated. Therefore, given the absence of recent previous studies, we considered the most adverse case to be when p=q=0.511. Hence, the estimated size of the sample for each FC was 250 individuals, which already predicted an estimated 10% loss. After data collection, there were a total of 246 respondents for each family clinic.
The CFFC has 14 Family Health Strategy (FHS) teams and partnerships with medical residency, nursing, and multidisciplinary programs. All of its teams have been part of the PRMFC-Rio for approximately 10 years. At CFNC, there are eight FHS teams, and at the time of data collection, there were three teams that had general physicians with no specialization in FCM, who worked for 40 hours a week in those teams and for more than two years.
Data collection was conducted in the health facilities after the users had finished a doctor’s appointment, in a reserved environment, from June to August 2023. Four interns from the Family Health Internship of the Universidade Federal do Rio de Janeiro (UFRJ) worked in data collection, as did the author herself. The selected users were approached alternately after leaving an appointment. The PCATool-Brasil questionnaire was used, in a reduced version, transcribed into the KoboTool digital platform, which is free of access, and observing the rules described in the PCATool 2020 Manual. This 25-item version evaluated reproductivity and was safe to use12. The extensive version was used for longitudinality. It includes the items from the reduced version, but it also enables the calculation of the average of an attribute separately, in addition to the overall PHC score.
The answers were scored according to a Likert scale, with the following categories: for sure, yes; probably, yes; probably, not; for sure not; do not know/cannot remember. The PCATool scores are classified as High (score≥6.6) and Low (score<6.6). When the average is higher or equal to 6.6, we may infer that there is the presence and extension of the PHC attributes, which represents better oriented PHC services13.
The questionnaire presented to the users sought to measure the longitudinality score separately and the overall PHC score for each unit. In addition to these items, we also analyzed the “affiliation” score, an item of the PCATool that assesses the identification with the health facility by the users, as being “their own”. The scores were correlated with the clinics and with the user profile to determine key factors, such as sex, race, and marital status. These profiles and the clinics were then compared, considering the presence or not of medical residency. For the purpose of data analysis, the variable “age” was stratified in two groups, according to the median value (45 years of age).
This study was submitted to and approved by the Ethics and Research Committee of the ENSP/Fiocruz, logged under protocol no. 5,906,217 and of the Municipal Health Secretary of Rio de Janeiro, logged under protocol no. 6,008,838, respecting the ethical aspects involving research with humans and following Resolution CNS No. 466/2012 of the National Commission on Research Ethics (Comissão Nacional de Ética em Pesquisa - CONEP).
Results
The results are described below according to the findings for each of the health facilities where data collection was conducted. For the purpose of comparison, the population was characterized according to sociodemographic variables; the calculation was made for the overall PHC score according to the reduced version of the PCATool-Brasil, and was longitudinally calculated for each of the facilities.
Of the 492 valid questionnaires, 246 collected at the CFFC, and 246 at the CFNC, eight were considered as invalid due to the score’s calculation, as the asnwer “I don’t know/I do not remember” was chosen in more than 50% of the answers or because the data presented was incomplete (“missing”). According to the instrument manual’s recommendations, this would render the final average unfeasible.
As regards sociodemographic data (data not tabulated), there was a predominance of the female sex among the interviewees in both facilities, with a total of 192 women (78.05%) and 54 men (21.95%) at the CFFC and 178 women (72.36%) and 68 men (27.64%) at the CFNC. In terms of age brackets, we found 130 patients, aged 45 years and younger (52.85%), at the CFFC, and 119 users, aged 45 years and younger (48.97%) at the CFNC. When asked about which skin color/race they identified themselves with, 174 (70.73%) at the CFFC and 170 (69.11%) at the CFNC identified themselves as brown/black. Concerning the marital status of the participants, 47.56% at the CFFC were married, as compared to 44.9% at the CFNC.
Evaluation of healthcare services in the perspective of adult users
Regarding the application of the PCATool, the average overall PHC score was 5.63 [5.46; 5.80]; of longitudinality, 6.22 [6.04; 6.40]; and of affiliation, 7.63 [7.37; 7.89]. When considered separately, at the CFFC, the overall PHC score could be calculated for 243 users, with a 6.32 average [6.12; 6.53]. The longitudinality score was calculated for 245 users, with a 7.02 average [6.81; 7.23]. The affiliation average was 7.87 [7.52; 8.23]. At the CFNC, the overall score had an average of 4.94 [4.70; 5.19]. The average longitudinality score was 5.43 [5.17; 5.68]. Finally, the affiliation score had an average of 7.38 [7.02; 7.51] (Table 1).
When the scores were correlated according to sex, we noticed a lower score given by males, in the overall score (6.40 [6.16; 6.36]), in longitudinality (7.08 [6.83; 7.32]), and in the affiliation to CFFC (8.06 [7.67; 8.44]). The estimates for the females, by contrast, were, respectively, 6.06 [5.66; 6.47]; 6.81 [6.38; 7.26]; and 7.22 [6.40; 8.05]. The same relationship was not observed at the CFNC, which showed an even higher evaluation by males for longitudinality and the overall PHC score. In that facility, for females, we obtained a overall score of 4.85 [4.56; 5.14]; 5.35 for longitudinality [5.05; 5.66]; and 7.57 [7.16; 7.97] for affiliation. The averages for the male public were 5.18 [4.71; 5.65]; 5.26 [5.16; 6.08]; and 6.91 [6.11; 7.72], respectively (Table 2).
In relation to age groups, a better evaluation was found among users over 45 years of age, interviewed at both clinics. The overall PHC score was 6.00 [5.7;6.29]; the longitudinality, 6.73 [4.42;7.04]; and the affiliation, 7.20 [6.71; 7.74] for interviewees aged 56 years and younger at the CFFC. For individuals over 45 years, at the same facility, the average score was 6.67 [6.38; 6.96]; longitudinality, 7.35 [7.06; 7.63], and affiliation, 8.62 [8.20;9.04]. At the CFNC, the averages for users, aged 45 years and younger, were 4.83 [4.46; 5.19]; 5.12 [4.73; 5.51]; and 7.25 [6.71; 7.80], respectively. Among interviewees over 45 years of age, the scores were 5.05 [4.72; 5.38]; 5.72 [5.39; 6.05]; and 7.5 [7.01; 8.00], respectively (Table 3).
When the interviewees’ skin color was correlated with the final score, the average overall PHC, longitudinality, and the affiliation scores, for people who self-reported themselves to be white, indigenous, or yellow, was 6.49 [6.15; 6.84]; 7.19 [6.86; 7.52]; and 8.29 [7.75; 8.83], respectively, while among those who self-reported themselves to be brown/black, the scores were 6.25 [6.00; 6.51]; 6.95 [6.68; 7.22]; and 7.70 [7.26; 8.15], respectively. At the CFNC, in the same order, the averages for those who self-reported themselves to be white/indigenous/yellow were 4.80 [4.38; 5.23]; 5.21 [4.75; 5.67]; and 7.76 [7.11; 8.41], respectively, while those who self-reported themselves to be brown/black were 5.05 [4.72; 5.38]; 5.72 [5.39; 6.05]; and 7.50 [7.01; 8.00], respectively (Table 4).
Average overall (95%CI), longitudinality, and affiliation scores according to race/skin color and affiliation by race/skin color in Primary Health Care (PHC) in the perspective of the adult users of the Felippe Cardoso and Nilda Campos Family Clinics. Municipality of Rio de Janeiro, June to August 2023.
Regarding the variable “marital status”, at the CFFC, the averages for overall, longitudinality, and affiliation scores for users who have a spouse were 6.32 [6.04; 6.61]; 7.05 [6.74; 7.35]; and 7.58 [7.06; 8.10], respectively. For those who are separated/widowed, these scores were 6.31 [5.97; 6.64]; 6.95 [6.60; 7.30]; and 8.10 [7.56; 8.64], respectively, for single individuals, the averages were 6.39 [5.72; 7.06]; 7.17 [6.56; 7.78]; and 8.28 [7.12; 9.43], respectively. At the CNFC, the patients who were married/in a stable union had averages of 4.86 [4.50; 5.23]; 5.31 [4.93; 5.69]; and 7.30 [6.75; 7.85], respectively, for the overall PHC, longitudinality, and affiliation scores. For the widowed/separated, the scores were 5.02 [4.63; 5.42]; 5.48 [5.07; 5.89]; and 7.39 [6.77; 8.01], respectively, for the same items and order mentioned above. Finally, those who were single showed the following averages: 4.98 [4.34; 5.61]; 5.62 [4.95; 6.29]; and 7.60 [6.75; 8.44] (Table 5).
Discussion
This study evaluated and compared longitudinality and the overall PHC score in the perspective of the users of two facilities from a region of Rio de Janeiro - one with teams of medical residency from PRMFC-Rio and another, with professionals that do not have this tie. The results showed a positive relationship between the presence of PRMFC-Rio and the presence and extension of longitudinality and other attributes, with better evaluations given by users of that facility.
Evaluation in health can perform a strategic role in the improvement of the quality of healthcare services, as well as in the reduction of inequalities and in guidance for public policies. However, the evaluation process still has not been incorporated into the healthcare systems in Brazil due to the hurdles that are inherent to this practice, such as a scarcity of resources, fragmentation of the healthcare system, and the lack of integration between the different levels of healthcare14.
The tool chosen for this study has been used more often in Brazil, perhaps because of its easy reproduction, understanding, and low cost15. I was also adopted by the IBGE in 2019, with the support of the Department for Primary Health Care (PHC) of the Ministry of Health, in the National Health Survey (NHS)16.
The analysis of the sociodemographic profile aids in understanding the characteristics and needs of the population, identifying barriers for access and inequalities in health. Among the participants of this study, most were females; brown or black; and single, separated, and/or widowed. This profile is similar to that found in a study conducted in Rio de Janeiro in 2014, in which interviewed adults were mostly females, other than white, with an age average of 46.96 years, with average of 2.62 children per adult, and mostly single/widowed/separated/divorced10.
We can also see parallels with the study conducted by the IBGE, which, for the first time, included a module for PHC evaluation in its population survey. Although it is impossible to isolate the profile of the population of the municipality of Rio de Janeiro in the results from that study, when compared to the Southeast region of the country, we find a population with a similar profile, in which 69.59% of the participants were female, 56.33% were brown or black, 37.79% had no spouse, and 54.53% received up to one minimum salary of income16.
The similarity in the profiles of the studies indicates lack of use of the facilities by males and the younger population, and a greater access by brown/black women to these facilities, which represents a sign for administrators to enhance policies aimed at that group. One hypothesis for this profile may be related to cultural aspects regarding health care, as well as the social role of the male and the relationship with the idea of fragility17.
The average overall PHC scores obtained in the present study are similar to what was found by a study conducted in 2014 in Rio de Janeiro, in which 3,530 adults participated in the survey and answered the PCATool questionnaire, resulting in an overall score of 5.73 [5.60; 5.84], an affiliation score of 7.05 [6.83; 7.27], and a longitudinality score of 6.27 [6.1; 6.40] in the municipality of Rio de Janeiro. More specifically, in CAP 3.1, the overall score was 6.0 [5.7; 6.29], the longitudinality score was 7.46 [6.91; 8.00], and the affiliation score was 6.26 [5.9; 6.6]10. Likewise, another study conducted in 2019 by the IBGE, obtained an average overall score for RJ of 5.3 [5.6; 5.9] and for the Southeast region of 5.8 [5.7; 6.0]16.
We can therefore conclude that, when comparing the two facilities, that which has a medical residency program showed high scores for affiliation and longitudinality and an overall score that was higher than the facility with no medical residency program, even though it did not reach the cutoff for configuring the presence and extension of PHC attributes. This may well be a consequence of the policies from the previous administration, which expressively reduced the FHC teams. Hence, we are now in a period in which dismantled health services need to be recovered.
Data indicates that there is improvement in quality of care when teams have medical residents, with better overall evaluations, which is also true for longitudinality, when compared to teams that have no FCM specialists. The higher evaluation of the “longitudinality” attribute for teams with residency programs indicates that longitudinal connections are being established regardless of the PRMFC-Rio, with the persistent presence of preceptors in the teams, who are professionals qualified to supervise the development of FCM capabilities.
It is important to mention, however, that even though the users were approached for interviews in a random manner, after leaving their medical appointments, the study had, as a limitation, the fact that it involved only the users who attend the facilities, while it does not include all of the people registered in the area. This can result in bias in the final results when they are extrapolated for the entire population.
The FHS proposal, as the main model of PHC, requires specialized professionals who are knowledgeable about the attributes designed by Starfield, and who have a more integral and reflexive view focused on the individual18. In 2013, a study was conducted in Rio de Janeiro focused on the implementation of the family clinics, which included the application of the PCATool, Health Professionals version. This tool classified the doctors as specialists (with residency or specialization in FCM/Family Health), or not, thus resulting in a difference in the average scores of the results, with higher scores for the medical specialists9.
Besides the association between more effectiveness of PHC and the presence of specialized doctors in the area, longitudinality and the establishment of longitudinal connections are directly related to the number of years worked by the health professionals, and to the establishment of a relationship between the professionals and the users. Many studies indicated that medical residency favors the maintenance of professionals in the places where they were trained19. Longitudinal connections allow the professionals or the teams to get to know the users in a more complete manner, building a relationship with more trust, and in so doing, achieving better resolutions to the problems that might be presented18.
When comparing the results of this study with other experiences of user evaluations conducted in different municipalities, we found results close to those presented herein, such as in the case of the study conducted in 2014 in Minas Gerais, with an overall score of 5.9220; a study in Fortaleza in 2019, with an overall score of 5.7 and of 6.40 for longitudinality21; another conducted in Campo Grande, Mato Grosso do Sul (2020), with an overall score of 5.5 and of 7.2 for longitudinality, considering that this final study was high in comparison to the units with no residency programs identified in the present study22.
Although comparative analyses are productive and aid in decision-making, by observing other realities, it is important to reiterate the diversity of our country and its continental dimensions, which justifies the identification of diverging results in different municipalities.
Final considerations
The residents of PRMFC-Rio are hosted at family clinics, under the supervision of preceptors who are family doctors, with closely supervised preceptory during the two years of training for the service. A strong preceptory, with professionals who are qualified in the field and with set contracts that allow them to stay for two years in the teams, facilitates the development of PHC attributes, including longitudinal connections.
The present study used the PCATool, in a reduced version for adult users, with a complete application of the longitudinality component, and observed that clinics with residency programs in FCM were evaluated well by the users. The longitudinality component obtained a 7.02 score, considered high according to the PCATool, in contrast with the clinic without the PRMFC-Rio, which presented an average of 5.43. The overall score showed expressive differences, with a 6.32 average in the former and a 4.94 score in the latter. Hence, we were able to establish relationships between the presence of PRMFC-Rio and the satisfaction of the users with the health service.
This study is relevant, especially considering the growing demand for evaluation processes which may aid administrators to make the necessary adjustments in order to expand PHC in Rio de Janeiro, as well as for the ongoing improvement in work processes and in the care provided by PHC. This study’s findings reinforce the importance of investment in residency programs and in the specialization of PHC professionals in order to improve the quality of PHC in Rio de Janeiro.
The reduced version of the PCATool constitutes a partial limitation of the study, since it is impossible to detail the contribution of each attribute to the final score. Hence, we chose to include the more complete attribute “longitudinality” in the approach. However, considering its easy replication, the reduced version serves as an timely tool, and may be applied in a more regular manner, mainly in scenarios of limited human resources, as well as financial resources and available time.
The use of this tool, whether in its extended or reduced format, allows for evaluations in a more accessible and affordable manner, and makes it possible to identify the presence and extension of PHC attributes over time, through the carrying out of evaluation surveys in series. There is a need for further studies on the theme, with studies conducted in other realities, exploring other attributes and considering the role of residency programs in relation to clinical outcomes. In so doing, these new studies may well help to improve the health care provided to the population in general.
The results of the present study revealed a positive evaluation of the longitudinal connections related to residency programs in FCM in the municipality of Rio de Janeiro, and this indicates a better performance of this attribute and potential to provide better care for all users within this context.
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Publication Dates
-
Publication in this collection
21 Oct 2024 -
Date of issue
Nov 2024
History
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Received
08 Mar 2024 -
Accepted
26 Apr 2024 -
Published
28 Apr 2024
