Taxa e custos médicos diretos de cesáreas em beneficiárias da saúde suplementar no estado de São Paulo, Brasil: 2015 a 2021 / Rate and direct medical costs of cesarean sections among supplementary health plan holders living in the state of São Paulo, Brazil: 2015-2021

Resumo O Brasil tem a segunda maior taxa de cesárea do mundo. Há diferença dessas taxas nos setores públicos e privados. Foram utilizados dados de internação de beneficiárias residentes no estado de São Paulo, internadas entre 2015 e 2021, com idades entre 10 e 49 anos, para verificar as taxas e custos das cesáreas no setor privado. Foi realizado estudo parcial de avaliação econômica em saúde na perspectiva da saúde suplementar considerando custos médicos diretos de internação. Foram analisadas 757.307 internações, com gasto total de R$ 7,701 bilhões. As taxas de cesáreas foram de 80% no período. São menores nas gestantes mais novas (69%) e maiores nas mais velhas (86%), e sempre superiores a 67%. Essa população tem taxas 71% maiores do que aquelas do SUS. Há maior proporção de internações com uso de unidade de terapia intensiva nas cesáreas. O custo mediano da cesárea é 15% maior do que o parto normal e são duas vezes maiores nas seguradoras do que nas cooperativas médicas. Há oportunidade de aplicação de políticas públicas de saúde amplamente utilizadas no Sistema Único de Saúde visando a redução das taxas, dos custos diretos da internação e dos planos de saúde.

Abstract Brazil has the second largest cesarean section rate in the world. Differences in rates exist between the public and private health sectors. This study used data on admissions of supplementary health plan holders aged between 10 and 49 years living in the state of São Paulo admitted between 2015 and 2021 to determine cesarean section rates and costs in the private health sector. We conducted a partial economic analysis in health from a supplementary health perspective focusing on the direct medical costs of admissions. A total of 757,307 admissions were analyzed with total costs amounting to R$7.701 billion. The cesarean section rate over the period was 80%. Rates were lowest in young women (69%) and highest in the oldest age group (86%), exceeding 67% across all groups. The rate was 71% higher than in public services. The proportion of admissions with use of the intensive care unit was higher among cesarian deliveries. The median cost of a cesarean was 15% higher than that of a normal delivery and twice as high in insurance companies than healthcare cooperatives. There is an opportunity to apply policies that are widely used in public services to the private sector with the aim of reducing cesarean rates in private services, direct costs of admission, and the cost of supplementary health plans.

Comparação de custos da terapia de reposição enzimática empírica com terapia guiada por diagnóstico laboratorial da insuficiência pancreática / Costs comparison of empirical enzymatic replacement therapy with laboratory diagnosis guided therapy of pancreatic insufficiency

Introdução: a fibrose cística, também conhecida como mucoviscidose, é uma doença genética cujas manifestações resultam da disfunção do gene cystic fibrosis transmembrane conductorance regulator. Cerca de 85% dos indivíduos com essa doença desenvolvem insuficiência pancreática exógena. Objetivo: comparar os custos da terapia de reposição enzimática empírica com a terapia de reposição enzimática empírica guiada pelo teste da elastase fecal, em indivíduos com fibrose cística, acompanhados em um centro de referência para assistência à doença. Metodologia: realizou-se um estudo descritivo e comparativo, que incluiu indivíduos de 0 a 21 anos, com fibrose cística. Coletaram-se dados referentes ao período de janeiro de 2016 a fevereiro de 2020, com registros clínicos, demográficos e laboratoriais. Inicialmente, com base em critérios clínicos, os participantes foram classificados como suficientes pancreáticos ou insuficientes pancreáticos. Após o resultado da dosagem da elastase fecal, o diagnóstico do status pancreático foi reavaliado. Realizouse a estimativa dos custos do teste da elas tase fecal por participante e da terapia por reposição enzimática empírica da insuficiência pancreática em indivíduos que, posteriormente, foram diagnostica dos como suficientes pancreáticos. Resultados: incluíram-se 50 participantes, com média de idade de 9,4 anos, sendo 52% do sexo masculino. Após o resultado da dosagem da elastase fecal, 7 participantes considerados insuficientes pancreáticos e foram reclassificados como suficientes pancreáticos. No período estudado, a economia média estimada, por participante suficiente pancreático, com a suspensão das enzimas, após resultado da elastase fecal, foi de R$ 6.770,13. Conclusão: a terapia de reposição enzimática empírica no tratamento da insuficiência pancreática pode levar a custos desnecessários. A medida de dosagem da elastase fecal contribui para decisão mais objetiva da avaliação da função pancreática.

Introduction: Cystic fibrosis, also known as mucoviscidosis, is a genetic disorder whose manifestations result from dysfunction of the cystic fibrosis transmembrane conductance regulator gene. About 85% of individuals with this disease develop exogenous pancreatic insufficiency. Objetivo: to compare the costs of empirical enzyme replacement therapy with fecal elastase test-guided empirical enzyme replacement therapy in individuals with cystic fibrosis followed up at a referral center for disease care. Methodology: a descriptive and comparative study was carried out, which included individuals aged 0 to 21 years, with cystic fibrosis. Data for the period from January 2016 to February 2020 were collected, with clinical, demographic and laboratory records. Initially, based on clinical criteria, participants were classified as pancreatic sufficient or pancreatic insufficient. After the result of the fecal elastase measurement, the diagnosis of pancreatic status was reassessed. Estimates were made of the costs of the fecal elastase test per participant and of the empiric enzyme replacement therapy for pancreatic insufficiency in individuals who were later diagnosed as pancreatic sufficient. Results: fifty participants were included, with a mean age of 9.4 years, 52% male. After the result of the fecal elastase measurement, 7 participants considered as pancreatic insufficient were reclassified as pancreatic sufficient. In the period studied, the estimated mean savings, per sufficient pancreatic participant, with the suspension of enzymes, after the result of fecal elastase, was R$ 6,770.13. Conclusion: empirical enzyme replacement therapy in the treatment of pancreatic insufficiency can lead to unnecessary costs. The measurement of fecal elastase dosage contributes to a more objective decision on the assessment of pancreatic function.

O desperdício de materiais assistenciais percebido por graduandos de enfermagem / The waste of assistance material perceived by nursing students

O estudo teve como objetivo identificar a opinião dos graduandos de enfermagem sobre o desperdício de materiais assistenciais nas atividades práticas de ensino. Estudo exploratório, descritivo com abordagem quantitativa, cuja amostra foi composta por 186 graduandos que responderam a um instrumento com assertivas medidas pela escala de Likert. Mais da metade dos graduandos acreditaram que as instituições onde realizaram estágio têm desperdício de materiais; 76% dos graduandos da quarta série (p<0,001) reconheceram desperdiçar materiais durante os estágios e 89% da mesma série (p<0,001) atribuíram o desperdício à realização de um procedimento pela primeira vez. O estudo possibilitou a discussão do desperdício de materiais durante a graduação em enfermagem, alertando sobre a importância da gestão adequada desses recursos além da responsabilidade da enfermagem com o meio ambiente e práticas sustentáveis. Os achados indicam novas possibilidades para o desenvolvimento do tema e estratégias que podem ser testadas em futuros estudos.

The study aimed to identify the opinion of nursing students about the waste of assistance materials in practical learning activities. We conducted an exploratory, descriptive study with a quantitative approach. One hundred and eighty-six students composed the sample and they answered to an instrument with affirmatives measured by a Likert-type scale. More than half of students believed that institutions where they are interns waste materials; 76% of fourth grade students (p<0.001) acknowledged to waste materials during their internships and, 89% of the same year (p<0.001) attributed waste to conducting a procedure for the first time. The study allowed the discussion about waste materials during nursing training, alerting about the importance of adequate management of these resources besides the nursing responsibility with the environment and sustainable practices.

Custos atribuídos às infecções de sítio cirúrgico em um Hospital Universitário em Salvador-Bahia. Brasil / Costs attributed to surgical site infection in a university hospital in Salvador, Bahia. Brazil

INTRODUÇÃO: As Infecções de Sítio Cirúrgico (ISCs) são as complicações mais freqüentes que ocorrem nos pacientes após as cirurgias e são responsáveis pela elevação da morbidade, mortalidade e dos custos hospitalares. OBJETIVO: O objetivo deste estudo foi estimar o custo direto adicional associado às ISCs ocorridas no período de 2011 a 2013 em um Hospital Universitário de Salvador, Bahia. Para tanto buscou-se caracterizar a população de pacientes acometidos por ISC, segundo os aspectos sócio-demográficas, condições clínicas e cirurgias realizadas, realizar uma revisão integrativa atualizada da literatura mundial sobre o custo dessas infecções e analisar os custos associados aos cuidados à saúde dos pacientes cirúrgicos segundo presença de ISC. METODOLOGIA: Trata-se se um estudo epidemiológico do tipo caso-controle pareado, realizado com informações dos registros hospitalares dos pacientes. Foram incluídos como população do estudo todos os casos de ISCs em cirurgias eletivas e limpas. Os controles foram pareados por idade, sexo e tipo de cirurgia realizada respeitando o princípio da similaridade. As proporções foram comparadas por meio dos testes 2 e exato de Fisher quando adequados com nível de 5% de significância estatística. Para estimar as diferenças das médias de custos utilizou-se o modelo de regressão linear. RESULTADOS: No total foram selecionados 259 pacientes. Os casos de ISC ocorreram predominantemente em mulheres, com idade entre 61 a 75 anos. Os principais fatores atribuídos aos custos com as ISCs foram o uso de antibióticos para o seu tratamento, a internação em Unidade de Terapia Intensiva, a realização de exames e reabordagens cirúrgicas. No geral, o custo médio hospitalar em pacientes com ISC foi aproximadamente o dobro do valor aferido daqueles não infectados. CONCLUSÕES: Foi evidenciado neste estudo a necessidade de reforçar o desenvolvimento constante de ações preventivas e de controle das ISCs a fim de garantir a segurança na assistência prestada aos pacientes cirúrgicos e conseqüentemente a redução dos custos atribuídos a essa complicação para o hospitais e sistema de saúde.

INTRODUCTION: The Surgical Site Infections (SSI) are the most frequent complications occurring in patients after surgery and are responsible for high morbidity, mortality and hospital costs. OBJECTIVE: The aim of this study was to estimate the additional direct costs associated with SSIs occurred in the 2011-2013 period at a University Hospital in Salvador, Bahia. For that sought to characterize the population of patients affected by ISC, according to the socio-demographic aspects, clinics and surgeries conditions, carry out a integrative and updated review of the literature on the cost of these infections and analyze the costs associated with health care to patients surgical according to the presence of ISC. METHODOLOGY: This is an epidemiological study of the case-control matched, conducted with information from the hospital records of patients. They were included in the study population all cases of ISCs in elective surgery and clean. The controls were matched for age, gender and type of surgery performed respecting the principle of similarity. Proportions were compared using the Fisher's exact test and χ2 when appropriate and at 5% statistical significance. To estimate the differences of the average costs used the linear regression model. RESULTS: In total 259 patients were selected. The cases of ISC occurred primarily in women between 61-75 years. The main factors attributed to the costs of the ISCs were the use of antibiotics for their treatment, to stay in the Intensive Care Unit, conducting exams and news surgical interventions. Overall, the average hospital cost in patients with SSI was approximately twice with those not infected. CONCLUSIONS: It was shown in this study the need of to reinforce the constant development of preventive and control of SSIs in order to secure the assistance provided to surgical patients and therefore reducing costs attributed to this complication for hospitals and health care system.

Evidence-based estimation of health care cost savings from the use of omega-3 supplementation among the elderly in Korea

BACKGROUND/OBJECTIVES: By the year 2050, thirty-eight percent of the Korean population will be over the age of 65. Health care costs for Koreans over age 65 reached 15.4 trillion Korean won in 2011, accounting for a third of the total health care costs for the population. Chronic degenerative diseases, including coronary heart disease (CHD), drive long-term health care costs at an alarming annual rate. In the elderly population, loss of independence is one of the main reasons for this increase in health care costs. Korean heath policies place a high priority on the prevention of CHD because it is a major cause of morbidity and mortality. SUBJECTS/METHODS: This evidence-based study aims to the estimate potential health care cost savings resulting from the daily intake of omega-3 fatty acid supplementation. Potential cost savings associated with a reduced risk of CHD and the medical costs potentially avoided through risk reduction, including hospitalizations and physician services, were estimated using a Congressional Budget Office cost accounting methodology. RESULTS: The estimate of the seven-year (2005-2011) net savings in medical costs resulting from a reduction in the incidence of CHD among the elderly population through the daily use of omega-3 fatty acids was approximately 210 billion Korean won. Approximately 92,997 hospitalizations due to CHD could be avoided over the seven years. CONCLUSIONS: Our findings suggest that omega-3 supplementation in older individuals may yield substantial cost-savings by reducing the risk of CHD. It should be noted that additional health and cost benefits need to be revisited and re-evaluated as more is known about possible data sources or as new data become available.

Un aspecto crítico olvidado con frecuencia: la adherencia al tratamiento / A critical aspect often neglected: adherence

Aun cuando la importancia del tratamiento adecuado y de su cumplimento para alcanzar las metas en salud están claramente demostrados, la falla de adherencia al tratamiento en general supera el 50%. Este es un problema multidimensional donde el paciente es sólo uno de los factores involucrados. Comprender los diferentes factores involucrados así como el impacto de la no adherencia no solamente en la falla de eficacia, sino en el incremento de riesgo y de costos para el sistema de salud, es clave para poder generar acciones que lleven a mejorar la. En Estados Unidos solamente, los costos incrementales relacionados con la no adherencia se calculan por encima de los 300 millardos de dólares.

Although the importance of proper treatment and its compliance to achieve health goals is clearly demonstrated, the failure in treatment adherence generally exceeds 50%. The lack of treatment adherence is a multidimensional problem where the patient is just one of the factors involved. Understanding the different factors in question and the impact of failure in treatment adherence not only in the efficiency, but the increase in risk and cost in the health system, are key for generating actions that lead to improvement. In the U.S. alone incremental costs associated with non-adherence are calculated above 300 billion.

Morbidities from Lack of Exercise and the Socioeconomic Effects

Lack of exercise may be one of the main causes of obesity in the recent modernized society. With the rapid increase of obese population worldwide, the economic costs of overweight have become a great burden in many countries. The costs of obesity may be divided into the direct costs to the health system and the indirect or social costs to the individuals and the community (for example, sick days and individuals' expenditure on weight loss). The direct costs depend on the main part of the diseases caused by obesity and the cost of these diseases. Some diseases thathave been included in the calculation are Type 2 diabetes, heart disease, hypertension, endometrial cancer, arthritis and colorectal cancer. One of the problems in this assessment is the relative risk of the diseases in different communities and ethnic groups. Several methods have been used to calculate these costs and produceda wide range of results from different countries. One of the latest estimates ofcosts of obesity is from the United States and was 10.2% of the total health care cost. Little data is yet available in Asian countries; however, the Korean Obesity Society reported a total cost of obesity estimated at about 0.11 % of GDP or about 2.13% of the total health care cost. It is now necessary to develop a strategy for life style modifications at the nationwide level.