Estrutura familiar e dinâmica educacional entre gerações / Family structure and educational dynamics between generations / Estructura familiar y dinámica educativa entre generaciones

O presente estudo busca identificar o impacto da estrutura familiar (biparentais e uniparentais) sobre a dinâmica educacional intergeracional e a acumulação de capital humano. Foram utilizados os microdados da Pesquisa Nacional por Amostra de Domicílio (PNAD) de 2014. A dinâmica educacional intergeracional foi analisada a partir de matrizes de transição e de processos de Markov. As diferenças de acumulação de capital humano entre as categorias de estruturas familiares foram investigadas a partir da decomposição de Blinder-Oaxaca. Os resultados indicam que ser dependente, do sexo feminino e residir na zona urbana são características associadas a uma maior mobilidade intergeracional de educação. O Nordeste se destaca como a região com menor mobilidade intergeracional educacional. A decomposição de Blinder-Oaxaca indica que, em média, as famílias uniparentais chefiadas por uma mulher possuem 0,5 ano de estudo a mais do que as uniparentais chefiadas pelo pai. Cerca de 74,2% dessa diferença é explicada pelo modelo estimado e a parte não explicada não possui significância estatística. Os resultados sugerem que a estrutura familiar afeta a dinâmica intergeracional de educação e a acumulação de capital humano dos indivíduos.

Objective. The present study seeks to identify the impact of the family structure (two-parent and one-parent) on the intergenerational educational dynamics and the accumulation of human capital. Method. The microdata from the National Household Sampling Survey (PNAD) of 2014 were used. The intergenerational educational dynamics was analyzed based on transition matrices and Markov processes. Differences in human capital accumulation between categories of family structures were investigated based on the Blinder-Oaxaca decomposition. Results. Results indicate that being dependent, female and living in the urban area are characteristics associated with greater intergenerational education mobility. The Northeast region stands out as the region with the lowest educational intergenerational mobility. The decomposition of Blinder-Oaxaca indicates that, on average, single-parent families headed by a woman have 0.5 years of study more than single-parent families headed by a father. About 74.2% of this difference is explained by the estimated model and the unexplained part has no statistical significance. Conclusion. Results suggest that the family structure affects the intergenerational dynamics of education and the accumulation of human capital of individuals.

Objetivo. El presente estudio busca identificar el impacto de la estructura familiar (biparental y monoparental) sobre la dinámica educativa intergeneracional y la acumulación de capital humano. Método. Se utilizaron los microdatos de la Encuesta Nacional de Muestreo de Hogares (PNAD) de 2014. Se analizó la dinámica educativa intergeneracional a partir de matrices de transición y procesos de Markov. Las diferencias en la acumulación de capital humano entre categorías de estructuras familiares se investigaron con base en la descomposición Blinder-Oaxaca. Resultados. Los resultados indican que ser dependiente, ser mujer y vivir en el área urbana son características asociadas a una mayor movilidad educativa intergeneracional. La nordestina se destaca como la región con menor movilidad educativa intergeneracional. La descomposición de Blinder-Oaxaca indica que, en promedio, las familias monoparentales encabezadas por una mujer tienen 0,5 años de estudio más que las familias monoparentales encabezadas por el padre. Aproximadamente el 74,2 % de esta diferencia se explica por el modelo estimado y la parte inexplicada no tiene significación estadística. Conclusión. Los resultados sugieren que la estructura familiar afecta la dinámica intergeneracional de la educación y la acumulación de capital humano de los individuos.

Continuo ascenso de la prevalencia de diabetes mellitus en mujeres chilenas en edad fértil: proyección 2020-2039 de malformaciones congénitas por diabetes pregestacional

Background: In Chile, in the next 20 years there will be an average number of 537,100 women of childbearing age with type 2 diabetes (T2DM). Half of these women, not knowing their diagnosis of diabetes will become pregnant with elevated glycosylated hemoglobin levels, increasing to 25% the risk of having offspring with congenital malformations. Aim: To calculate the cost-effectiveness of a diabetes detection strategy in women of childbearing age for the prevention of congenital malformations in the period 2020-2039. Material and Methods: The Markov stochastic model was used in two scenarios, namely A: No intervention and B: Intervention, detecting T2DM in Chilean women aged 15-49 years. We calculated the years of life lost due to premature death (YLL), years of life lost adjusted for disability (DALY) and total costs using American dollars (US$) of 2017, with a discount rate of 5%. Results: In scenario A: 63,330 children with malformations would be born, YLLs and DALYs would be 800,750 and 1,544,775 respectively, and US$ 10,194,298,011 would be expended. In scenario B, these figures would be reduced in approximately 70% to 19,025 children born with malformations, YLLS and DALYs would be 40,539 and 464,033 respectively and US$ 3,354,321,968 would be expended. The costs of prevention would be US$ 6,590.94/malformation avoided, US$ 521.33/YLL avoided, and US$ 270.24/DALY avoided. Conclusions: In the context of an increasing prevalence of diabetes in women of childbearing age, our results suggest that the early detection of diabetes in Chilean women between 15 and 49 years of age, should be cost-effective to avoid an increase in congenital malformations for the next 20 years.

Economic evaluation of fifteen cervical cancer screening strategies in rural China / 中华妇产科杂志

Objective To evaluate the feasible cervical cancer screening strategies in rural China. Methods The study was based on the health industry scientific research project of National Health Commission in 2015, cervical cancer screening technology and demonstration research suitable for rural areas in China, we collected health economics and epidemiological parameters and established the unscreening model and screening model with Treeage Pro 2011 software. Combining with the data acquired from site investigation, including population screening, treatment-related clinical materials and cost data, we simulated the occurrence and the development of cervical cancer of rural women in China under different screening and intervention programs and predicted the screening effects [cumulative incidence, cumulative risk of disease, life years and quality adjusted life years (QALY), gains] and costs after 20 years, and using health economic evaluation analysis (cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis). Screening programs included five screening strategies [visual inspection with acetic acid/lugol's iodine (VIA/VILI), careHPV, ThinPrep cytology test (TCT), careHPV+TCT, careHPV+VIA/VILI] and three screening intervals (1-year, 3-year, 5-year), a total of fifteen screening programs. Results Compared with no screening, fifteen screening programs reduced the cumulative incidence by 22.65%-51.76%. Compared with TCT or VIA/VILI, for the same screening interval, the reduced cumulative incidence, the amounts of life-year saved and QALY and benefits gained of careHPV were the highest. The cost-effectiveness ratios of these screening programs ranged (0.44-3.24)×104 Yuan per life-year saved, cost-utility ratios ranged (0.15-1.01)×104 Yuan per QALY, benefit-cost ratios ranged 7.73-59.10. The results of incremental cost-effectiveness ratios showed that VIA/VILI every five years, VIA/VILI every three years, careHPV every five years, careHPV every three years and careHPV every year were dominant programs. Conclusions VIA/VILI screening is cost-effective, careHPV is slightly more expensive but more effective. In rural China, careHPV screening every five years could be recommended. This study provides a basis for the determination of cervical cancer screening methods feasible for rural areas in China.

Economic evaluation of fifteen cervical cancer screening strategies in rural China / 中华妇产科杂志

Objective@#To evaluate the feasible cervical cancer screening strategies in rural China.@*Methods@#The study was based on the health industry scientific research project of National Health Commission in 2015, cervical cancer screening technology and demonstration research suitable for rural areas in China, we collected health economics and epidemiological parameters and established the unscreening model and screening model with Treeage Pro 2011 software. Combining with the data acquired from site investigation, including population screening, treatment-related clinical materials and cost data, we simulated the occurrence and the development of cervical cancer of rural women in China under different screening and intervention programs and predicted the screening effects [cumulative incidence, cumulative risk of disease, life years and quality adjusted life years (QALY) , gains] and costs after 20 years, and using health economic evaluation analysis (cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis). Screening programs included five screening strategies [visual inspection with acetic acid/lugol's iodine (VIA/VILI), careHPV, ThinPrep cytology test (TCT), careHPV+TCT, careHPV+VIA/VILI] and three screening intervals (1-year, 3-year, 5-year), a total of fifteen screening programs.@*Results@#Compared with no screening, fifteen screening programs reduced the cumulative incidence by 22.65%-51.76%. Compared with TCT or VIA/VILI, for the same screening interval, the reduced cumulative incidence, the amounts of life-year saved and QALY and benefits gained of careHPV were the highest. The cost-effectiveness ratios of these screening programs ranged (0.44-3.24)×104 Yuan per life-year saved, cost-utility ratios ranged (0.15- 1.01)×104 Yuan per QALY, benefit-cost ratios ranged 7.73-59.10. The results of incremental costeffectiveness ratios showed that VIA/VILI every five years, VIA/VILI every three years, careHPV every five years, careHPV every three years and careHPV every year were dominant programs.@*Conclusions@#VIA/VILI screening is cost-effective, careHPV is slightly more expensive but more effective. In rural China, careHPV screening every five years could be recommended. This study provides a basis for the determination of cervical cancer screening methods feasible for rural areas in China.

Evaluación de la costo-efectividad de un modelo integral de tratamiento ambulatorio en pacientes con síndrome coronario agudo: aplicación de un modelo de Markov probabilístico / Evaluation of the cost-effectiveness of an integral model of ambulatory treatment in patients with acute coronary syndrome: application of a probabilistic Markov model / Avaliação da relação custo-eficácia de um modelo integral de tratamento ambulatorial em pacientes com síndrome coronariana aguda: aplicação de um modelo probabilístico de Markov

RESUMEN Objetivo Evaluar la costo-efectividad de un modelo integral de tratamiento ambulatorio en pacientes que presentaron un síndrome coronario agudo. Métodos Se realizó una evaluación económica a partir de un estudio de intervención cuasi-experimental, que incluyó 442 pacientes con edades entre 30 y 70 años, quienes presentaron un síndrome coronario agudo. El grupo de intervención (n = 165) recibió un modelo integral de tratamiento ambulatorio fundamentado en el cuidado gestionado (disease management), mientras que el grupo control (n = 277) recibió rehabilitación cardiovascular convencional. Durante un año de seguimiento, se evaluó la presentación de reeventos cardiovasculares y hospitalizaciones. Se desarrolló un modelo de Markov probabilístico. La perspectiva de estudio se aplicó dentro del Sistema General de Seguridad Social en Salud Colombiano, incluidos los costos sanitarios directos; el horizonte temporal fue de 50 años con descuentos de 3,42% para costos y efectividades; y la medida de efectividad fue los años de vida ganados ajustados por calidad. Se realizó un análisis de sensibilidad probabilístico y multivariante mediante de la simulación de Montecarlo. Resultados Durante el año de seguimiento, los costos directos relacionados con el valor pagado fueron en promedio de USD 2 577 para el grupo control y USD 2 245 para el grupo de intervención. En el análisis de sensibilidad probabilístico, 91,3% de las simulaciones se ubicaron en el cuadrante correspondiente a costos incrementales negativos y efectividades incrementales positivas (intervención evaluada de menor costo, más efectiva). En las simulaciones, se observó un ahorro promedio anual por paciente de USD 1 215 por cada año de vida ganado ajustado por calidad. Conclusiones El modelo integral de tratamiento ambulatorio implementado en pacientes que sufrieron un síndrome coronario agudo mostró ser menos costoso y más efectivo en comparación con el cuidado convencional. Por ser una alternativa dominante, se recomienda como modelo de cuidado en esta población.

ABSTRACT Objective To evaluate the cost-effectiveness of an integral model of ambulatory treatment in patients who presented an acute coronary syndrome. Methods An economic evaluation was made from a quasi-experimental intervention study, which included 442 patients aged 30 to 70 years who presented an acute coronary syndrome. The intervention group (n = 165) received an integral model of ambulatory treatment based on managed care (disease management), while the control group (n = 277) received conventional cardiovascular rehabilitation. During one year of follow-up, the presentation of cardiovascular events and hospitalizations was evaluated. A probabilistic Markov model was developed. The study perspective was applied within the General System of Health Social Security in Colombia, including the direct health costs; the time horizon was 50 years with discounts of 3.42% for costs and effectiveness; and the measure of effectiveness was quality-adjusted life years (QALYs). A probabilistic and multivariate sensitivity analysis was performed using the Montecarlo simulation. Results During the year of follow-up, the direct costs related to the value paid were, on average, USD 2 577 for the control group and USD 2 245 for the intervention group. In the probabilistic sensitivity analysis, 91.3% of the simulations were located in the quadrant corresponding to incremental negative costs and positive incremental effectiveness (evaluated intervention at a lower cost, more effective). In the simulations, an average annual savings per patient of USD 1 215 per QALY was observed. Conclusions The integral model of ambulatory treatment implemented in patients who suffered an acute coronary syndrome was found to be less expensive and more effective compared to conventional care. Considering it is a dominant alternative, it is recommended as a model of care in this population.

RESUMO Objetivo Avaliar a relação custo-eficácia de um modelo integral de tratamento ambulatorial em pacientes que apresentaram síndrome coronariana aguda. Métodos Uma avaliação econômica foi feita a partir de um estudo de intervenção quase experimental, que incluiu 442 pacientes com idade entre 30 a 70 anos que apresentaram síndrome coronariana aguda. O grupo de intervenção (n = 165) recebeu um modelo integral de tratamento ambulatorial com base em cuidados gerenciados (gerenciamento de doenças), enquanto o grupo controle (n = 277) recebeu reabilitação cardiovascular convencional. Durante um ano de acompanhamento, foi avaliada a apresentação de eventos cardiovasculares e hospitalizações. Um modelo probabilístico de Markov foi desenvolvido. A perspectiva do estudo foi aplicada no Sistema Geral de Segurança Social na Saúde da Colômbia, incluindo os custos diretos de saúde; o horizonte temporal foi de 50 anos com descontos de 3,42% em custos e efetividade; e a medida de eficácia foi os anos de vida ajustados pela qualidade (QALY). Uma análise de sensibilidade probabilística e multivariada foi realizada utilizando a simulação de Montecarlo. Resultados Durante o ano de acompanhamento, os custos diretos relacionados ao valor pago foram, em média, USD 2 577 para o grupo controle e USD 2 245 para o grupo de intervenção. Na análise de sensibilidade probabilística, foram localizadas 91,3% das simulações no quadrante correspondente a custos negativos incrementais e eficácia incremental positiva (intervenção avaliada a menor custo, mais efetiva). Nas simulações, observou-se uma economia anual média por paciente de US $ 1 215 por QALY. Conclusões O modelo integral de tratamento ambulatorial implementado em pacientes que sofreram síndrome coronariana aguda foi considerado menos caro e mais eficaz em comparação com os cuidados convencionais. Por ser uma alternativa dominante, é recomendado como modelo de cuidados nesta população.

Lessons and perspectives for applications of stochastic models in biological and cancer research

The effects of randomness, an unavoidable feature of intracellular environments, are observed at higher hierarchical levels of living matter organization, such as cells, tissues, and organisms. Additionally, the many compounds interacting as a well-orchestrated network of reactions increase the difficulties of assessing these systems using only experiments. This limitation indicates that elucidation of the dynamics of biological systems is a complex task that will benefit from the establishment of principles to help describe, categorize, and predict the behavior of these systems. The theoretical machinery already available, or ones to be discovered to help solve biological problems, might play an important role in these processes. Here, we demonstrate the application of theoretical tools by discussing some biological problems that we have approached mathematically: fluctuations in gene expression and cell proliferation in the context of loss of contact inhibition. We discuss the methods that have been employed to provide the reader with a biologically motivated phenomenological perspective of the use of theoretical methods. Finally, we end this review with a discussion of new research perspectives motivated by our results.

Simple but not simpler: a systematic review of Markov models for economic evaluation of cervical cancer screening

The aim of this study was to critically evaluate the quality of the models used in economic evaluations of screening strategies for cervical cancer prevention. We systematically searched multiple databases, selecting model-based full economic evaluations (cost-effectiveness analyses, cost-utility analyses, and cost-benefit analyses) of cervical cancer screening strategies. Two independent reviewers screened articles for relevance and performed data extraction. Methodological assessment of the quality of the models utilized formal checklists, and a qualitative narrative synthesis was performed. Thirty-eight articles were reviewed. The majority of the studies were conducted in high-income countries (82%, n=31). The Pap test was the most used screening strategy investigated, which was present in 86% (n=33) of the studies. Half of the studies (n=19) used a previously published Markov model. The deterministic sensitivity analysis was performed in 92% (n=35) of the studies. The mean number of properly reported checklist items was 9 out of the maximum possible 18. Items that were better reported included the statement of decision problem, the description of the strategies/comparators, the statement of time horizon, and information regarding the disease states. Compliance with some items of the checklist was poor. The Markov models for economic evaluation of screening strategies for cervical cancer varied in quality. The following points require improvement: 1) assessment of methodological, structural, heterogeneity, and parameter uncertainties; 2) model type and cycle length justification; 3) methods to account for heterogeneity; and 4) report of consistency evaluation (through calibration and validation methods).

Cadenas de markov aplicadas al análisis de la ejecución de proyectos de investigación / Markov chains applied to the analyzis of the progress of research projets

La administración moderna requiere el apoyo de herramientas de diferentes ramas de la ciencia que ayuden al proceso de toma de decisiones, como por ejemplo la Matemática Aplicada. En este contexto aparecen variables aleatorias que con el transcurso del tiempo cambian, y que pueden ser representadas a través de modelos cuantitativos. Cuando en estos modelos el estado presente de dichas variables resume toda la información anterior para describir cómo se comportarán en el futuro, se dice que se está en presencia de una cadena de Markov; una herramienta eficiente para el análisis de procesos de esta naturaleza, como por ejemplo la ejecución de proyectos de investigación, el cual reviste gran importancia en la gestión de ciencia e innovación tecnológica; área de resultados clave en cualquier universidad. En la Facultad de Tecnología de la Universidad de Ciencias Médicas de Santiago de Cuba, el análisis de la ejecución de los proyectos de investigación se consideró como una cadena de Markov, definiendo los diferentes estados por los que puede estar un proyecto, y las probabilidades de que este se encuentre en un estado determinado a partir del estado en que se encontraba. Así se determinaron elementos que permiten apoyar la toma de decisiones a corto y a largo plazo, a partir de datos históricos durante el trienio 2013 - 2015, relacionados con la cantidad promedio de inspecciones a los mismos, probabilidades de un proyecto cerrar, etc.; permitiendo pronosticar en términos de probabilidades el estado de este subsistema en el futuro(AU)

Modern management tools require support from different branches of science to help the decision-making process, such as Applied Mathematics. In this context, random variables with change over time, and that can be represented by quantitative models appear. When these models in the present state of these variables summarizes all the previous information to describe how they will behave in the future, it is said that we are in the presence of a Markov chain; an efficient tool for the analysis of processes of this nature, such as the execution of research projects, which is of great importance in the management of science and technological innovation; key result area at any university. In the Faculty of Technology, University of Medical Sciences of Santiago de Cuba, the analysis of the implementation of research projects was considered as a Markov chain, defining the different states through which can be a project and the odds of this is in a certain state from the state it was. And support elements that enable decision-making in the short and long term, from historical data in the period 2013 - 2015 were determined, related to the average number of inspections to a project, the probability of a project likely to close, etc.; allowing to predict in terms of probabilities the status of this subsystem in the future(AU)

Predição volumétrica de lesões pulmonares aplicando modelo oculto de Markov / Prediction volumetric of lung lesions applying hidden Markov model

OBJETIVO: predizer o estado volumétrico de lesões pulmonares aplicando o modelo oculto de Markov (HMM). MATERIAIS E MÉTODOS: Aquisição de imagens de lesões pulmonares temporais, geração do HMM e a aplicação do HMM. RESULTADOS: Os testes foram aplicados em 24 lesões pulmonares, adquiridas da Public Lung Database to Address Drug Response (PLDADR). Dividimos os resultados desta pesquisa em 3. O primeiro utilizando a base completa para predição volumétrica da lesão e comparação com o Response Evaluation Criteria in Solid Tumors (RECIST), atingindo uma taxa de acerto de 70,83%. No segundo, Aplica - se o método leave-one-out, separando os dados em dois grupos, treino e teste, obtendo-se uma taxa de acerto de 75,00%. Por fim, realizamos a predição volumétrica de cada lesão no intervalo de 5 tempos. O resultado mostrou que é possível predizer se o estado da lesão está progredindo, regredindo ou estabilizando, a partir das alterações ocorridas nos diâmetros e volumes.

OBJECTIVE: predicting the volume status of lung lesions by applying the hidden Markov model (HMM). MATERIALS AND METHODS: Acquisition of images of temporal lung lesions, HMM generation and application of HMM. RESULTS: The tests were applied in 24 pulmonary lesions, acquired from Public Lung Database to Address Drug Response(PLDADR). We have divided this search in 3. The first using the full volumetric basis for prediction of the lesion and compared to the Response Evaluation Criteria in Solid Tumors (RECIST), reaching a 70.83% success rate. Then, weapply the leave-one-out method, separating the data into two groups, training and testing, yielding a 75.00% successrate. Finally, we volumetric prediction of each lesion in 5 days interval. The result showed that it is possible to predict the state of the injury is progressing, regressing or stabilizing, from changes in the diameters and volumes.

Modelos de decisão para avaliações econômicas de tecnologias em saúde / Decision modeling for economic evaluation of health technologies

A maioria das avaliações econômicas que participam dos processos de decisão de incorporação e financiamento de tecnologias dos sistemas de saúde utiliza modelos de decisão para avaliar os custos e benefícios das estratégias comparadas. Apesar do grande número de avaliações econômicas conduzidas no Brasil, há necessidade de aprofundamento metodológico sobre os tipos de modelos de decisão e sua aplicabilidade no nosso meio. O objetivo desta revisão de literatura é contribuir para o conhecimento e o uso de modelos de decisão nos contextos nacionais das avaliações econômicas de tecnologias em saúde. Este artigo apresenta definições gerais sobre modelos e preocupações com o seu uso; descreve os principais modelos: árvore de decisão, Markov, microssimulação, simulação de eventos discretos e dinâmicos; discute os elementos envolvidos na escolha do modelo; e exemplifica os modelos abordados com estudos de avaliação econômica nacionais de tecnologias preventivas e de programas de saúde, diagnósticas e terapêuticas.

Most economic evaluations that participate in decision-making processes for incorporation and financing of technologies of health systems use decision models to assess the costs and benefits of the compared strategies. Despite the large number of economic evaluations conducted in Brazil, there is a pressing need to conduct an in-depth methodological study of the types of decision models and their applicability in our setting. The objective of this literature review is to contribute to the knowledge and use of decision models in the national context of economic evaluations of health technologies. This article presents general definitions about models and concerns with their use; it describes the main models: decision trees, Markov chains, micro-simulation, simulation of discrete and dynamic events; it discusses the elements involved in the choice of model; and exemplifies the models addressed in national economic evaluation studies of diagnostic and therapeutic preventive technologies and health programs.

Markov Models in health care / Modelos de Markov aplicados a saúde

Markov Chains provide support for problems involving decision on uncertainties through a continuous period of time. The greater availability and access to processing power through computers allow that these models can be used more often to represent clinical structures. Markov models consider the patients in a discrete state of health, and the events represent the transition from one state to another. The possibility of modeling repetitive events and time dependence of probabilities and utilities associated permits a more accurate representation of the evaluated clinical structure. These templates can be used for economic evaluation in health care taking into account the evaluation of costs and clinical outcomes, especially for evaluation of chronic diseases. This article provides a review of the use of modeling within the clinical context and the advantages of the possibility of including time for this type of study.

Os modelos de Markov prestam apoio aos problemas de decisão envolvendo incertezas em um período contínuo de tempo. A maior disponibilidade e o maior acesso no poder de processamento por meio dos computadores permite que esses modelos possam ser utilizados mais frequentemente para representar estruturas clínicas. Os modelos de Markov consideram os pacientes em um estado discreto de saúde, e os eventos representam a transição de um estado para outro. A possibilidade de modelar eventos repetitivos e a dependência temporal das probabilidades e utilidades associadas permitem uma representação mais precisa da estrutura clínica avaliada. Esses modelos podem ser utilizados para avaliações econômicas em saúde levando em consideração a avaliação dos custos e desfechos clínicos (outcomes), especialmente para a avaliação de doenças crônicas. Este artigo oferece uma revisão do uso dessa modelagem dentro do contexto clínico e as vantagens da possibilidade da inclusão temporal para esse tipo de estudo.

Estudo de custo-efetividade do anastrozol adjuvante no câncer de mama em mulheres pós-menopausa / Cost-effectiveness analysis of adjuvant anastrozol in post-menopausal women with breast cancer

OBJETIVOS: Análise econômica com dados nacionais sobre a possível incorporação do anastrozol como terapia adjuvante hormonal no câncer de mama em pacientes pós-menopausa. MÉTODOS: Foi feita estimativa de custo-efetividade no tratamento adjuvante do câncer de mama, em mulheres pós-menopausa, do anastrozol versus tamoxifeno em três perspectivas: do paciente, de planos de saúde e do governo. Modelo de Markov foi desenvolvido utilizando dados extraídos de publicação do estudo ATAC após seguimento de 100 meses, com projeção de desfechos em 25 anos para uma coorte hipotética de 1000 pacientes com câncer de mama pós-menopausa no Brasil. Dados de utilização de recursos e custos associados foram obtidos de fontes preestabelecidas e de opinião de especialistas. O custo associado aos tratamentos foi extraído separadamente, dependendo do ponto de vista estudado. O benefício foi inserido no modelo para obtenção do custo por ano de vida ganho ajustado pela qualidade (QALY). RESULTADOS: Extrapolando benefícios encontrados para 25 anos de seguimento, o anastrozol, em relação ao tamoxifeno, resultou numa estimativa de ganho de 0,29 QALY. A razão de custo-efetividade por QALY ganho dependeu da perspectiva utilizada. Houve incremento de R$ 32.403,00/QALY no ponto de vista do SUS; de R$ 32.230,00/QALY no dos planos de saúde; e de R$ 55.270,00/QALY no das pacientes. CONCLUSÃO: O benefício encontrado no uso do anastrozol adjuvante em pacientes com câncer de mama operado na pós-menopausa está associado a grandes diferenças na razão de custo-efetividade, dependendo da perspectiva utilizada para o cálculo. Comparando com parâmetros usualmente aceitos pela OMS, o incremento é aceitável sob a perspectiva do SUS e dos planos de saúde, mas não sob a ótica do paciente.

OBJECTIVES: Carry out an economic analysis of the incorporation of anastrozole as adjuvant hormone therapy in postmenopausal women with breast cancer in a Brazilian setting. METHODS: The cost-effectiveness estimate comparing anastrozole to tamoxifen was made from the perspectives of the patient, private health insurance, and government. A Markov model was designed based on data from ATAC trial after 100 months follow-up in a hypothetical cohort of 1000 postmenopausal women in Brazil, using outcomes projections for a 25-year period. Resource utilization and associated costs were obtained from preselected sources and specialists' opinions. Treatment costs varied according to the perspective used. The incremental benefit was inserted in the model to obtain the cost of quality-adjusted life-year gained (QALY). RESULTS: Benefit extrapolations for a 25-year time line showed an estimate of 0.29 QALY gained with anastrozole compared to tamoxifen. The cost-effectiveness ratio per QALY gained depended on which perspective was used. There was an increment of R$ 32.403,00/QALY in the public health system/government, R$ 32.230,00/QALY for private health system, and R$ 55.270,00/QALY for patients. CONCLUSION: The benefit from adjuvant anastrozole in postmenopausal patients with breast cancer is associated to major differences in cost-effectiveness ratio and varies with the different perspectives. According to current WHO parameters, the increment is considered acceptable under public and private health system perspectives, but not from that of the patient.

Cost-effectiveness of anastrozole, in comparison with tamoxifen, in the adjuvant treatment of early breast cancer in Brazil / Custo-efetividade do anastrozol em comparação com tamoxifeno no tratamento adjuvante do câncer de mama precoce no Brasil

OBJECTIVE: Breast cancer, a leading type of cancer in many developing countries, is the most frequent non-cutaneous tumor in Brazil. Hormone therapy is the standard of care in the adjuvant treatment of early-stage, hormone-receptor-positive disease, and both tamoxifen and third-generation aromatase inhibitors are options in postmenopausal women. The comparative cost-effectiveness of different treatment strategies is of considerable interest in societies facing limited resources. METHODS: In an attempt to compare cost-effectiveness of upfront treatment with tamoxifen or anastrozole, the medical and economic results in a hypothetical cohort of 64-year-old postmenopausal women, was analyzed considering the Brazilian healthcare system in 2005, the primary perspective of the private sector, and a lifetime horizon. Data from the ATAC Trial, Markov modeling, a modified Delphi panel, and microcosting (in Brazilian R$) were used to estimate costs and effectiveness of the two upfront strategies. RESULTS: The model estimated a gain of 0.55 discounted life-years for patients receiving anastrozole, relative to those treated with tamoxifen. With an incremental cost of R$ 15,141.15, the model estimated that the cost-effectiveness of anastrozole, in relation to tamoxifen, was R$ 27,326.80. Monte Carlo simulations showed that approximately 50 percent of the cases fell below the threshold of R$ 29,229.00 per life-year gained, which is recommended by the World Health Organization for Brazil. CONCLUSION: It was concluded that upfront anastrozole is a cost-effective option compared with tamoxifen in the adjuvant treatment of postmenopausal women with hormone-receptor-positive early breast cancer.

OBJETIVO: O câncer de mama, o mais comum em vários países desenvolvidos, é o tumor não cutâneo mais frequente no Brasil. A terapia hormonal é o tratamento adjuvante padrão para os estágios precoces, em doença com receptor hormonal positivo, e o tamoxifeno e os inibidores da aromatase de terceira geração são opções para mulheres na pós-menopausa. A comparação do custo-efetividade dos diferentes tratamentos é de grande interesse nas sociedades com limitações de recursos. MÉTODOS: Para comparar a custo-efetividade dos tratamentos com tamoxifeno ou anastrozol, foram analisados os resultados médicos e econômicos em uma coorte hipotética de mulheres com 64 anos de idade, considerando o sistema de saúde Brasileiro em 2005, sob a perspectiva do setor privado e o horizonte de tempo de uma vida. Usamos dados do Estudo ATAC, um modelo de Markov, um painel de Delphi modificado, e micro-costing (em reais R$) para estimar os custos e a efetividade das duas estratégias. RESULTADOS: O modelo estimou um ganho de 0.55 anos de vida descontados para pacientes recebendo anastrozol em relação àquelas tratadas com tamoxifeno. Com um custo marginal de R$ 15.141,15, o modelo estimou que o custoefetividade do anastrozol em relação ao tamoxifeno era de R$ 27.326,80. As simulações de Monte Carlo mostraram que aproximadamente 50 por cento dos casos estavam abaixo do limite de R$ 29.229,00 por ano-vida ganho, que é o recomendado pela Organização Mundial da Saúde para o Brasil. CONCLUSÃO: Nós concluímos que o anastrozol é uma opção custo-efetivo comparado ao tamoxifeno no tratamento adjuvante de câncer de mama precoce em mulheres na pós-menopausa com receptor de hormônio positivo.

Modelos empleados para la toma de decisiones en el cuidado de la salud / Models used for decision-making in health care

El análisis de decisiones es un grupo de herramientas que permiten apoyar y manejar un proceso de evaluación estructurado. Esta metodología se usa ampliamente en la evaluación económica para planeación o programas de salud. Este artículo delinea algunas características de las decisiones complejas y muestra los fundamentos y etapas que deben considerarse cuando se toman decisiones en un escenario de incertidumbre (definición del problema, selección de un marco temporal de análisis adecuado, estructuración del problema, desarrollo de un modelo para análisis, selección de la mejor alternativa y realización de análisis de sensibilidad). Finalmente se presentan algunas críticas que se han hecho a esta metodología.

Decision analysis consists of a set of tools supporting and handling structured evaluation. Such methodology is widely used for the economic evaluation of health care planning and programmes. This article outlines some characteristics regarding complex decision-making and shows the fundamental issues and stages considered when making decisions in an uncertain scenario (problem definition, choosing an appropriate time-frame, structuring the problem, developing a model for analysing it, selecting the best alternative and analysing sensitivity). Some criticism of this decision-making method is then made.

Cost-effectiveness analysis of two therapeutic methods for prolactinoma / 中华妇产科杂志

Objective To evaluate the therapeutic responses to transsphenoidal surgery and medical therapy in terms of normalization of prolactin(PRL),mortality,morbidity and the cost-effectiveness of PRL normalization in order to establish an individualized therapeutic protocol for the patients with prolactinoma.Methods A retrospective study was undertaken of a consecutive series of patients with prolactinoma who were followed for at least 1 year after transsphenoidal surgery or medical treatment.The clinical characteristics and the long-term outcomes(normalization of PRL,morbidity or mortality)were assessed.Utilizing the principle of medical economics and data from the two types of treatment,we worked out a Markov chain and calculated the lowest cost of two kinds of therapeutic protocols.Results(1)The success rate of normalizing serum PRL through surgical treatment in microadenoma was 85%(22/26),and that of medical treatment was 95%(19/20).There was no statistical difference between the two therapies(P＞0.05).The success rate of normalizing serum PRL through surgical treatment in macroadenoma was45%(19/42),and that of medical treatment was 5/5.There was a statistical difierence between the two therapies(P＜0.05).(2)According to the Markov model,it would cost a microprolactinoma patient 25 129.25 yuan to normalize serum PRL by surgical treatment.This is comparable to the cost of medical treatment which would be 24 943.99 yuan.Whereas for a macroprolactinoma patient surgery would cost 35 208.20 yuan and medical treatment would cost 25 344.38 yuan.Conclusions Medical therapy is superior to surgical treatment in regard to complication rate and cost-effectiveness for macro-and extra big prolactinomas.Transsphenoidal surgery remains an option for patients with microadenomas.Markov model is an effective way to predict the treatment cost for patients with hyperprolactinoma at different ages and with different canses