The influence of health expenditures on household impoverishment in Brazil / Influência dos gastos em saúde no empobrecimento de domicílios no Brasil

OBJECTIVE To analyze the variation in the proportion of households living below the poverty line in Brazil and the factors associated with their impoverishment. METHODS Income and expenditure data from the Household Budget Survey, which was conducted in Brazil between 2002-2003 (n = 48,470 households) and 2008-2009 (n = 55,970 households) with a national sample, were analyzed. Two cutoff points were used to define poverty. The first cutoff is a per capita monthly income below R$100.00 in 2002-2003 and R$140.00 in 2008-2009, as recommended by the Bolsa Família Program. The second, which is proposed by the World Bank and is adjusted for purchasing power parity, defines poverty as per capita income below US$2.34 and US$3.54 per day in 2002-2003 and 2008-2009, respectively. Logistic regression was used to identify the sociodemographic factors associated with the impoverishment of households. RESULTS After subtracting health expenditures, there was an increase in households living below the poverty line in Brazil. Using the World Bank poverty line, the increase in 2002-2003 and 2008-2009 was 2.6 percentage points (6.8%) and 2.3 percentage points (11.6%), respectively. Using the Bolsa Família Program poverty line, the increase was 1.6 (11.9%) and 1.3 (17.3%) percentage points, respectively. Expenditure on prescription drugs primarily contributed to the increase in poor households. According to the World Bank poverty line, the factors associated with impoverishment include a worse-off financial situation, a household headed by an individual with low education, the presence of children, and the absence of older adults. Using the Bolsa Família Program poverty line, the factors associated with impoverishment include a worse-off financial situation and the presence of children. CONCLUSIONS Health expenditures play an important role in the impoverishment of segments of the Brazilian population, especially among the most disadvantaged. .

OBJETIVO Analisar a variação na proporção de domicílios vivendo abaixo da linha de pobreza no Brasil e os fatores associados ao empobrecimento. MÉTODOS Foram analisados os dados de despesa e renda das Pesquisas de Orçamentos Familiares conduzidas no Brasil em 2002-2003 (n = 48.470 domicílios) e 2008-2009 (n = 55.970 domicílios) com amostra representativa nacional. Foram utilizados dois pontos de corte para definir pobreza. O primeiro, recomendado pelo Programa Bolsa-Família, considerou pobreza rendimento per capita mensal inferior a R$100,00 em 2002-2003 e a R$140,00 em 2008-2009. O segundo, proposto pelo Banco Mundial, incorpora a correção pela paridade do poder de compra, resultando em US$2,34 por dia, em 2002-2003, e US$3,54, em 2008-2009. Para identificar os fatores sociodemográficos associados ao empobrecimento dos domicílios foi utilizada regressão logística. RESULTADOS Houve acréscimo de domicílios vivendo abaixo da linha de pobreza no Brasil após subtração dos gastos em saúde. Considerando-se a linha de pobreza recomendada pelo Banco Mundial, em 2002-2003 o acréscimo foi 2,6 pontos percentuais (ou 6,8%) e, em 2008-2009, 2,3 pontos percentuais (ou 11,6%). Considerando-se a linha de pobreza utilizada pelo Programa Bolsa-Família, a variação foi 1,6 (11,9%) e 1,3 (17,3%), respectivamente. Gastos com medicamentos foram os que mais contribuíram para o aumento de domicílios pobres. Os fatores associados ao empobrecimento, segundo a linha de pobreza do Banco Mundial, foram apresentar pior situação econômica, ser chefiado por indivíduo com baixa escolaridade, presença de crianças e ausência de idosos. Utilizando-se a linha de pobreza do Bolsa-Família, os fatores associados foram apresentar pior situação econômica e presença de crianças. ...

Colaboração médico-farmacêutico no manejo de pacientes com diabetes mellitus tipo 2: expectativas e resultados / Physician-pharmacist collaboration in the management of patients with type 2 diabetes mellitus: expectations and outcomes

Nos últimos vinte anos houve um aumento substancial no número de revisões sistemáticas e ensaios clínicos que avaliaram intervenções farmacêuticas para pacientes com doenças crônicas, em especial o diabetes. No entanto, existem poucos estudos que avaliam criticamente tais publicações, bem como modelos de prática desenvolvidos no contexto do sistema público de saúde brasileiro. O presente trabalho teve como objetivos avaliar revisões sistemáticas e ensaios clínicos controlados randomizados sobre serviços clínicos farmacêuticos para pacientes com diabetes e avaliar o efeito de modelo de colaboração médico- farmacêutico conduzido em ambulatório de cuidado secundário para pacientes com diabetes tipo 2 não controlada. Para tanto, busca abrangente da literatura foi conduzida nas bases de dados PubMed, SCOPUS, LILACS, Scielo e DOAJ por revisões sistemáticas e ensaios clínicos controlados randomizados. As revisões sistemáticas foram avaliadas em relação à qualidade da apresentação textual e metodológica, sendo identificados campos para melhorias futuras. A seguir, foi realizada uma descrição dos componentes-chave das intervenções e fontes de heterogeneidade clínica e metodológica entre os ensaios clínicos controlados randomizados. Ainda, foi conduzido um ensaio clinico controlado randomizado no ambulatório de doenças metabólicas do Hospital Universitário da Universidade de São Paulo, com duração de 12 meses, para 80 pacientes com diabetes tipo 2 não controlada. O grupo intervenção recebeu consultas farmacêuticas face a face, com suporte remoto por telefone. O farmacêutico realizou intervenções sistemáticas objetivando resolver ou prevenir problemas relacionados aos medicamentos. Os desfechos primários incluíram a redução e controle dos níveis de hemoglobina glicada. A busca bibliográfica identificou 101 registros, dos quais sete revisões completaram os critérios de inclusão. Em média, apenas dois terços dos itens sobre qualidade da apresentação textual e metodológica foram cumpridos nas publicações. Os problemas mais frequentes incluíram o não registo de protocolo do estudo, a ausência de lista dos estudos excluídos, e a falta de reconhecimento claro do conflito de interesses. A busca por ensaios clínicos randomizados de intervenções farmacêuticas identificou 2271 registros, sendo incluídos 24 na síntese qualitativa. A maioria dos estudos para pacientes com diabetes tipo 2 foi desenvolvida nos Estados Unidos, em ambulatório, com contato individual face a face. Todos realizaram intervenções educativas e o processo de uso dos medicamentos foi avaliado pela maioria deles. A amostra exibiu risco de viés incerto ou alto na maior parte dos itens avaliados, o que resultou em baixa qualidade metodológica. De um total de 80 pacientes, 73 completaram o ensaio clínico, sendo 36 do grupo intervenção e 37 do controle. Comparado ao cuidado usual, o grupo intervenção apresentou maior redução nos níveis de hemoglobina glicada, bem como aumento na taxa de controle da pressão arterial sistólica, na proporção de pacientes aderentes e na pontuação da adesão. Os resultados desta tese apontam que a qualidade da apresentação textual e a metodológica estavam abaixo do ideal entre as revisões e que melhoria no desenho e na descrição das revisões e dos estudos primários é necessária para garantir resultados mais robustos. Ainda, o modelo de cuidado proposto é viável e mais efetivo que o cuidado usual na redução da hemoglobina glicada em pacientes diabéticos tipo 2

Over the last twenty years, there was an important increase in the number of systematic reviews and clinical trials about pharmacist interventions in patients with chronic diseases, including diabetes. Nevertheless, few studies exist which assess critically such publications, as well as models of practice developed in the context of the Brazilian Public Health System. The study aimed to assess the systematic reviews and randomized controlled trials on clinical pharmacy services for patients with diabetes and to assess the effect of a pharmacist- physician collaborative care model for patients with poorly controlled type 2 diabetes. For this, comprehensive literature search was performed in databases PubMed, SCOPUS, LILACS, Scielo and DOAJ for systematic reviews and randomized controlled trials. The systematic reviews were assessed for the reporting characteristics and methodological quality, been identified rooms for future improvements. The following, it was performed a description of the key components of pharmacist interventions and of the sources of clinical and methodological heterogeneity between randomized controlled trials. In addition, a 12-month randomized controlled trial of pharmacist-physician collaborative interventions for eighty diabetic patients was conducted at University Hospital of University of São Paulo. The pharmaceutical interviews were conducted face-to-face, with remote support by telephone. Pharmacist performed systematic interventions aiming to solve and prevent drug-related problem in the diabetic patients. The primary outcomes included the reduction and control of the levels of glycosylated hemoglobin. The literature search yielded 101 records, of which 7 reviews for diabetic patients satisfied the inclusion criteria. On average, only two-thirds of reporting and methodological quality items were fulfilled in included reviews. The most frequent problems included the non-registration of study protocol, the absence of a list of excluded studies, and unclear acknowledgment of the conflict of interests. The literature search for randomized clinical trials of pharmacist interventions identified 2271 records, 24 of them were included in the qualitative synthesis. The majority of studies was developed in the United States, in ambulatory, with individual contact face to face. All of them performed educational interventions and the process of use of the medications was assessed in the majority of them. The sample showed risk of bias uncertain or high in the majority of the items assessed, which resulted in low methodological quality. Of a total of 80 patients, 73 completed the clinical trial (37 of control and 36 of intervention). In comparison with the usual care, the intervention group presented higher reduction in the levels of glycosylated hemoglobin, as well as increase in the rate of control of the systolic blood pressure, in the proportion of adherent patients and in the score of the medication adherence. The results of this thesis point out that the report and methodological quality was below the ideal in the reviews and that improvement in the design and in the description of the reviews and of the primary studies is necessary to warrant results that are more robust. Still, the model of care proposed is viable and more effective than the usual care in reducing the levels of glycosylated hemoglobin in patients with diabetes type 2

Evaluación de Tecnología Sanitaria y su impacto en políticas de tarificación y cobertura de medicamentos / Health technology assessment and its impact on pharmaceutical pricing and reimbursement policies

The article conceptualizes the pharmaceutical pricing and reimbursement policies related to financial coverage in the context of health systems. It introduces the pharmaceutical market as an imperfect one, in which appropriate regulation is required. Moreover, the basis that guide the pricing and reimbursement processes are defined and described in order to generate a categorization based on whether they are intended to assess the 'added value' and if the evaluation is based on cost-effectiveness criteria. This framework is used to review different types of these policies applied in the international context, discussing the role of the Health Technology Assessment in these processes. Finally, it briefly discusses the potential role of these types of policies in the Chilean context.

Administración de ácido fólico y otros micronutrientes en mujeres embarazadas de Colombia / Administration of folic acid and other micronutrients to pregnant women in Colombia

OBJETIVO: Caracterizar el consumo de ácido fólico (AF) y otros micronutrientes en forma de medicamentos en un grupo de mujeres gestantes colombianas. MÉTODOS: Estudio observacional descriptivo. Se obtuvo información por medio de entrevistas a gestantes y de sus registros de historia clínica de control prenatal y/o atención del parto en cuatro ciudades de Colombia. La muestra fue de 1 637 mujeres atendidas en 15 instituciones. RESULTADOS: A 1 315 gestantes (80,3%) les recomendaron consumir AF, con prescripción realizada por médico al 84% de ellas; 90,3% adhirieron al tratamiento. A 85,6% el AF les fue suministrado por la empresa aseguradora de salud, y 10,7% lo compró de su bolsillo. La prescripción fue pertinente en 0,2% de las mujeres. Su consumo fue totalmente oportuno en 0,2% y totalmente inoportuno en 41,9% de las gestantes. A 1 192 mujeres (72,8%) les recomendaron otros micronutrientes; a 77,6% de ellas se los recomendó el médico, y 88,7% adhirieron al tratamiento. CONCLUSIONES: Se recomienda y se consume AF y otros micronutrientes de manera inadecuada, sin evaluar las necesidades individuales de las mujeres gestantes. Se invita a reflexionar sobre la utilidad de los programas que promueven el consumo masivo de micronutrientes en forma de medicamento durante el embarazo; los programas parecen desconocer las causas fundamentales de los problemas nutricionales que aquejan a la población.

OBJECTIVE: To characterize the intake of folic acid (FA) and other micronutrients in medicinal form in a group of pregnant women in Colombia. METHODS: Descriptive observational study. Information was obtained from interviews of pregnant women and from the clinical records of their prenatal check-ups and/or delivery in four cities in Colombia. The sample consisted of 1 637 women seen in 15 institutions. RESULTS: A total of 1 315 pregnant women (80.3%) were advised to take FA, and 84% received a prescription, 90.3% of whom adhered to the treatment. FA was provided to 85.6% of them by their health insurance company and 10.7% purchased it themselves. The prescription was appropriate for 0.2% of the women; its use was entirely appropriate for 0.2% of the pregnant women and totally inappropriate for 41.9%. Other micronutrients were recommended to 1 192 women (72.8%), 77.6% of whom received the advice from their physician, with 88.7% adhering to the treatment. CONCLUSIONS: FA and other micronutrients are inappropriately recommended to pregnant women and taken without assessing their individual needs. The usefulness of programs that promote mass consumption of micronutrients in medicinal form during pregnancy should be reexamined. These programs seem not to recognize the fundamental causes of the population's nutritional problems.

The impact of the healthcare system in Barbados (Provision of health insurance and the Benefit Service Scheme) on the use of herbal remedies by Christian churchgoers / El Impacto del sistema de salud en Barbados (Provisión de seguro de salud y Plan de Servicios y Beneficios) sobre el uso de remedios herbarios por parte de los feligreses Cristianos

AIM: To determine the impact of health insurance and the government's Benefit Service Scheme, a system that provides free drugs to treat mostly chronic illnesses to persons aged 16 to 65 years, on the use of herbal remedies by Christian churchgoers in Barbados. METHODS: The eleven parishes of Barbados were sampled over a six-week period using a survey instrument developed and tested over a four-week period prior to administration. Persons were asked to participate and after written informed consent, they were interviewed by the research team. The data were analysed by the use of IBM SPSS version 19. The data were all nominal, so descriptive statistics including counts, the frequencies, odds ratios and percentages were calculated. RESULTS: More than half of the participants (59.2%) were female, a little less than a third (29.9%) were male, and one tenth of the participants (10.9%) did not indicate their gender. The majority of the participants were between the ages of 41 and 70 years, with the age range of 51-60 years comprising 26.1% of the sample interviewed. Almost all of the participants were born in Barbados (92.5%). Approximately 33% of the respondents indicated that they used herbal remedies to treat various ailments including chronic conditions. The odds ratio of persons using herbal remedies and having health insurance to persons not using herbal remedies and having health insurance is 1.01 (95% CI 0.621, 1.632). There was an increase in the numbers of respondents using herbal remedies as age increased. This trend continued until the age group 71-80 years which showed a reduction in the use of herbal remedies, 32.6% of respondents compared with 38.3% of respondents in the 61-70-year category. CONCLUSIONS: The data demonstrated that only a third of the study population is using herbal remedies for ailments. Health insurance was not an indicator neither did it influence the use of herbal remedies by respondents. The use of herbal remedies may not be associated with affluence. The reduction in the use of herbal remedies in the age group 71-80 years could be due to primarily a lower response rate from this age group, and secondarily due to the Benefit Service Scheme offering free medication to persons who have passed the age of 65 years.

OBJETIVO: Investigar si el Seguro de Saludy el Plan de Servicios y Beneficios del Gobierno - un sistema que proporciona medicina libremente para tratar principalmente enfermedades crónicas en personas de 16 a 65 anos de edad - influyen en el uso de remedios herbarios por los feligreses cristianos en Barbados. MÉTODOS: Se realizó un muestreo en once provincias de Barbados por un período de seis semanas, usando como instrumento una encuesta desarrollada y probada durante un período de cuatro semanas antes de ser aplicada. Se le pidió participación a distintas personas y luego de obtener el consen-timiento informado por escrito, las mismas fueron entrevistadas por el equipo de investigación. Los datos fueron analizados mediante la versión 19 de IBM SPSS. Todos los datos eran nominales, de modo que se calcularon las estadísticas descriptivas, incluyendo conteos, frecuencia, cociente de probabilidades (odds ratio), y porcentajes. RESULTADOS: Más de la mitad de los participantes (59.2%) eran mujeres; poco menos de un tercio (29.9%) eran hombres; y una décima parte de los participantes (10.9%) no indicó su sexo. La mayoría de los participantes se encontraban entre las edades de 41 y 70 anos, para un rango de edad de 51-60 anos que comprendía el 26.1% de la muestra entrevistada. Casi todos los participantes nacieron en Barbados (92.5%). Aproximadamente 33% de los entrevistados indicaron que usaban remedios herbarios para tratar varias dolencias, incluyendo condiciones crónicas. El odds ratio de las personas que usan remedios herbarios y poseen seguro de salud es 1.01 (95% CI 0.621, 1.632). Seprodujo un aumento en el número de entrevistados que usaban remedios herbarios, según aumentaba su edad. Esta tendencia continuó hasta el grupo etario de 71-80 anos, el cual mostró una reducción en el uso de remedios herbarios, 32.6% de los entrevistados en comparación con el 38.3% de los entrevistados en la categoría de los 61-70 anos. CONCLUSIONS: Los datos mostraron que sólo una tercera parte de la población está usando remedios herbarios para sus dolencias. El seguro de salud no fue un indicador ni influyó sobre el uso de remedios herbarios por los entrevistados. El uso de remedios herbarios no puede asociarse con la afluencia. La reducción en el uso de remedios herbarios en el grupo etario 71-80 anos podrían deberse principalmente a una tasa de respuesta más baja de este grupo etario, y secundariamente al Plan de Servicios y Beneficios que ofrece medicamentos gratuitamente a personas que han pasado la edad de 65 anos.

Impact of the National Health Fund policy on hormone treatment for prostate cancer in Jamaica / Repercusión de un subsidio del Fondo Nacional de Salud en la hormonoterapia para el cáncer de próstata en Jamaica

OBJECTIVE: To compare the proportion of patients choosing surgical versus medical castration to treat prostate cancer, before and after the National Health Fund (NHF) of Jamaica began to subsidize hormone therapy. METHODS: A retrospective review was performed at the University Hospital of the West Indies (UHWI), Jamaica. The pathology database at UHWI was searched to identify patients who had prostate biopsies between January 2000 and December 2007. These were combined with records of biopsies at external institutions. Medical records of all patients with positive prostate biopsies were reviewed to determine if they had received androgen deprivation therapy (ADT). Patients were classified as having had surgical castration (bilateral orchiectomy) or medical castration. Chi-square statistics were used to determine the difference in proportions between those choosing medical versus surgical castration before and after March 2005, when the NHF began offering subsidies for ADT drugs. RESULTS: Of the 1 529 prostate biopsies performed during the study period, 680 (44.0 percent) cases of prostate cancer were diagnosed. Of these, 458 patients underwent ADT and had complete records available for analysis. The mean patient age was 72 years. During the entire study period, surgical castration was performed in 265 patients (58.0 percent) and medical castration in 193 (42.0 percent). A greater proportion of orchiectomies were performed before March 2005, rather than after (P < 0.001). Estrogens were the most common method of medical castration used before the NHF subsidy became available (62.0 percent); while luteinizing hormone-releasing hormone analogues (38.0 percent) and antiandrogens (36.5 percent) were most often chosen afterwards. CONCLUSIONS: Surgical castration was more common than medical castration before March 2005. After the NHF began to subsidize the cost of drugs for hormone therapy, medical castration was chosen more often. Increased access to drugs for hormone therapy has changed treatment patterns in Jamaica.

OBJETIVO: Comparar la proporción de pacientes que eligen la castración quirúrgica frente a la castración farmacológica para tratar el cáncer de próstata, antes y después de la creación de un subsidio del Fondo Nacional de Salud (NHF, por sus siglas en inglés) de Jamaica destinado a cubrir los costos de la hormonoterapia. MÉTODOS: Se llevó a cabo un examen retrospectivo en el Hospital Universitario de las Indias Occidentales, Jamaica. Se efectuó una búsqueda en la base de datos de enfermedades de dicho hospital para identificar a los pacientes a quienes se les había practicado una biopsia de próstata entre enero del 2000 y diciembre del 2007. Los datos se combinaron con los registros de biopsias llevadas a cabo en instituciones externas. Se estudiaron las historias clínicas de todos los pacientes con resultados positivos en la biopsia de próstata para determinar si habían recibido tratamiento de supresión androgénica. Los pacientes se clasificaron en dos grupos, según se hubieran tratado mediante castración quirúrgica (orquiectomía bilateral) o farmacológica. Se usó la prueba de la ji al cuadrado para determinar la diferencia en las proporciones entre los pacientes que escogieron la castración quirúrgica y los que escogieron la opción farmacológica antes y después de marzo del 2005, la fecha en la que el NHF empezó a subsidiar los medicamentos de supresión androgénica. RESULTADOS: Entre las 1 529 biopsias de próstata realizadas durante el período de estudio, hubo 680 (44,0 por ciento) casos con diagnóstico de cáncer de próstata. De estos, 458 pacientes habían recibido tratamiento de supresión androgénica y se disponía de sus registros completos para el análisis. La edad media de los pacientes fue de 72 años. Durante el período de estudio, se les practicó castración quirúrgica a 265 pacientes (58,0 por ciento) y castración farmacológica a 193 (42,0 por ciento). La proporción de orquiectomías fue mayor antes de marzo del 2005 que después de esa fecha (P < 0,001). Los estrógenos fueron el método de castración farmacológica más común antes de la creación del subsidio del NHF (62,0 por ciento); a partir de ese momento se eligieron con mayor frecuencia los análogos de la hormona liberadora de la hormona luteinizante (38,0 por ciento) y los antiandrógenos (36,5 por ciento). CONCLUSIONES: La castración quirúrgica era más común que la castración farmacológica antes de marzo del 2005. Después de que el NHF empezó a subsidiar el costo de los medicamentos para el tratamiento hormonal, la opción escogida con más frecuencia fue la castración farmacológica. El mayor acceso a los medicamentos usados en la hormonoterapia ha cambiado los patrones de tratamiento del cáncer de próstata en Jamaica.

Access to medicines by ambulatory health service users in Mexico: an analysis of the national health surveys 1994 to 2006 / Acceso a medicamentos para los usuarios del primer nivel de los servicios de salud: análisis de las encuestas nacionales de salud 1994, 2000 y 2006

OBJECTIVE: To analyse the medicines prescription, prescription filling, payment expenditure for medicines by ambulatory health service users (HSU) in 2006, and to evaluate its evolution in the last 12 years. MATERIAL AND METHODS: Using data from the National Health Surveys in 2006 three binary logistic regression models were constructed to identify the variables associated with the prescription rate, prescription filling and payment for medicines in 2006. The results of access to medicines were compared to the ones from previous National Health Services from 1994 and 2000. RESULTS: The type of health service provider was found to be the most important predictors of access to medicines. Although the proportion of HSU obtaining a prescription and paying for drugs has broadly stayed the same as in 1994, the percentage of HSU paying for their prescribed medicines decreased from 70 percent in 1994 to 42 percent at Ministry of Health institutions in 2006. CONCLUSION: The progress in prescription and population access to medicines has been uneven across health service providers.

OBJETIVO: Analizar la prescripción médica, surtimiento de recetas y gasto en medicamentos que tienen los usuarios del primer nivel de los servicios de salud (UPNS) en 2006 y evaluar su evolución en los últimos 12 años. MATERIAL Y MÉTODOS: Utilizando los datos de la Encuesta Nacional de Salud de 2006 se construyeron tres modelos de regresión logística para identificar los factores asociados con la prescripción, el surtimiento de medicamentos y el pago por medicamentos recetados. Se compararon los resultados del acceso a medicamentos con los de encuestas anteriores de 1994 y 2000. RESULTADOS: La variable más relevante para el acceso a medicamentos fue el tipo de institución donde se prestó atención. Aunque al nivel global la proporción de los UPNS que obtuvieron una prescripción y que pagaron por los medicamentos más o menos se mantuvo estable, el porcentaje de los UPNS que pagaron por los medicamentos en las instituciones de la Secretaría de Salud disminuyó de 70 a 42 por ciento entre 1994 y 2006. CONCLUSIÓN: El mejoramiento del acceso a medicamentos para usuarios de los servicios de salud ha sido desigual a través de las instituciones.

Caracterización de los servicios farmacéuticos de atención primaria del Sistema Único de Salud en Londrina, Paraná, Brasil / Description of the pharmaceutical services offered by the universal health care system at the primary care level in Londrina, Paraná, Brazil

OBJETIVOS: Caracterizar a los servicios farmacéuticos de atención primaria del Sistema Único de Salud (SUS) de Brasil. MÉTODOS: El estudio se llevó a cabo en Londrina, Paraná, Brasil, de enero a marzo de 2003. Se utilizaron los indicadores de uso de los medicamentos propuestos por la Organización Mundial de la Salud. Se incluyeron 13 unidades de atención primaria de salud, donde se entrevistaron 390 pacientes. RESULTADOS: Ninguna de las unidades contaba con un farmacéutico. El promedio de duración de la consulta médica fue de 8,6 minutos; el de medicamentos por prescripción, 2,2; y el de uso de inyectables, 10,9 por ciento. La denominación genérica se utilizó en 66,5 por ciento de las prescripciones y 73,3 por ciento de los medicamentos constaban en la Lista Municipal de Medicamentos Esenciales (Remume). Solamente 46,6 por ciento de los pacientes entrevistados refirieron tener la información mínima para usar correctamente los medicamentos prescritos. CONCLUSIÓN: Estos resultados pueden contribuir para la reorganización de los servicios farmacéuticos en el municipio, ya que señalan la necesidad del fortalecimiento y del uso racional de medicamentos como recursos terapéuticos necesarios para apoyar a las acciones de salud.

OBJECTIVES: To describe the pharmaceutical services offered at the primary care level by Brazil's Sistema Único de Salud (Universal Health Care System). METHODS: The study took place in Londrina, Paraná, in January-March 2003. The World Health Organization's recommended drug use indicators were employed. Included in the study were 13 primary health care facilities in which 390 patients were interviewed. RESULTS: None of the facilities had a pharmacist. The average office visit lasted 8.6 minutes; the mean number of drugs prescribed was 2.2; and injections were given in 10.9 percent. Generic drugs were prescribed 66.5 percent of the time and 73 percent of the prescribed drugs were included in the Lista Municipal de Medicamentos Esenciales (Municipal List of Essential Drugs). Only 46.6 percent of the patients interviewed reported having the basic instructions required for appropriate use of the drug prescribed. CONCLUSIONS: These results can aid in restructuring the municipality's pharmaceutical services because they underscore the need to improve and to increase rational drug use as a therapeutic resource imperative to supporting health efforts.

The Contributing Factors to Surplus Medicine by Long-Term Users of Medical Aid in Korea / 예방의학회지

OBJECTIVES: The amount of medical utilization by Medical Aid recipients was 3.7 times that of patients with Korean Medical Insurance. This study aims to describe the surplus medicine and the medication-related utilization, and to determine factors contributing to surplus medicine. METHODS: Among those who used copayment-free Class I Medical Aid in 2005, 146,880 subjects who were > or =19 year-old and received >365 days medical treatment per year were studied with their case managers by conducting face-to-face interviews. The analytic methods were description, chi-square, t-tests, ANCOVA and multiple logistic regressions. RESULTS: Most subjects were female (68.6%), the elderly (62.5%), and the separated (61.6%), had an elementary graduation or less (74.8%), and had disabilities (33.2%). The percentage of subjects with surplus medicine was 18.5%. However, the percentage of females, the elderly, those with non-disabilities, the separated, the uneducated, those with a very poor perceived health status and those with an economical burden for medical treatment was 19.3%, 18.9%, 19.0%, 19.3%, 19.0%, 20.2% and 24.3%, respectively. For subjects with surplus medicine, averages for the number of used pharmacies, the pharmacy-visit days and the medication costs were 4.6 drugstores, 34.9 days and approximately 1,124 thousand Won. These values were higher than those without surplus medicine (4.4 drugstores , 33.8 days, and 1,110 thousand won, respectively). The odds ratios of the contributing factors to surplus medicine were female 1.11 (95% CI=1.07-1.14), the elderly 1.06 (95% CI=1.02-1.10), those with non-disabilities 1.08 (95% CI=1.05-1.12), the separated 1.14 (95% CI=1.10-1.18), the unmarried 1.12 (95% CI=1.07-1.18), the uneducated 1.03 (95% CI=1.01-1.08), those with a very poor perceived health status 1.04 (95% CI=1.01-1.08) and experiencing an economical burden for medical treatment 2.33 (95% CI=2.26-2.40). CONCLUSIONS: 18.5% of subjects had surplus medicine with a higher mean of medication cost. Therefore, health education and health promotion programs to prevent surplus medicine and to improve the appropriate usage of medication are necessary.

Utilização de um sistema de gerenciamento de benefícios farmacêuticos (PBM) para a caracterização do perfil de prescrição e aquisição de antibióticos / Use of pharmacy banafits management (PBM) system to describe the profile of antibiotic prescription and purchase

No Brasil o PBM (Pharmacy Benefits Management) é de utilização relativamente nova, podendo-se classificá-lo como um sistema de gerenciamento de saúde que administra benefícios na compra e venda de medicamentos. Considerando que o surgimento de bactérias resistentes está relacionado à prescrição inapropriada de antibióticos ou ao uso de antibióticos de baixa atividade, este estudo avaliou se o sistema PBM pode fornecer informações úteis sobre os perfis de prescrição e aquisição de antibióticos de efeitos sistêmicos, a partir da base de dados de uma empresa de PBM brasileira, referente a um grupo formado por 6 525 metalúrgicos de uma empresa da região de Campinas, SP, e seus dependentes, cobrindo o período de janeiro a abril de 2005. Observou-se que 7,7 por cento de todos os medicamentos adquiridos eram antibióticos sistêmicos, numa média 2,4 antibióticos e ao custo de R$ 51,80 por receita. A amoxicilina foi o fármaco mais prescrito e em 92,7 por cento dos casos o usuário adquiriu o medicamento até um dia após a consulta médica. A partir das listas das especialidades farmacêuticas adquiridas (por unidade de venda), dos laboratórios fabricantes, dos antibióticos que compunham cada produto, das datas de emissão das receitas e da dispensação, foi possível concluir que o sistema permite extrair informações relevantes sobre o tema enfocado.

Pharmacy Benefits Management (PBM), a system that manages benefits in the purchase and sale of drugs, is of relatively recent implementation in Brazil. Taking into account that the development of bacterial resistance is related to the inadequate prescription of antibiotics or to the use of low activity antibiotics, this study sought to assess the capability of PBM to provide useful information on the profiles of prescription and purchase of systemic antibiotics. The data used for this purpose were collected from the database of a Brazilian PBM company and related to a group of 6 525 metalworkers of a company located in the region of Campinas, SP, and to their dependents, covering the period from January to April 2005. Of the drugs purchased, 7.7 percent were systemic antibiotics, with a mean of 2.4 antibiotics and a mean cost of R$ 51.80 per prescription. Amoxicillin was the most prescribed drug. In 92.7 percent of cases, users purchased the prescribed drug within one day of the medical visit. Based on the lists of purchased pharmaceutical specialties (per retail package), manufacturers, antibiotics present in the composition of each product, prescription dates, and dispensation dates, the system was found capable of providing relevant information on the theme investigated.

Surtimiento de recetas a los afiliados al Seguro Popular de Salud de México / Dispensing prescriptions to persons affiliated with Popular Health Insurance in Mexico

OBJETIVO: Medir y comparar el porcentaje de recetas surtidas completamente a los usuarios de servicios ambulatorios y de los hospitales generales de los Servicios Estatales de Salud de México (SESA) afiliados y no afiliados al Seguro Popular de Salud (SPS) según condición de aseguramiento, además de medir la satisfacción de los usuarios de los SESA con el acceso a los medicamentos. MATERIAL Y MÉTODOS: La información del estudio procede de cuatro encuestas de unidades ambulatorias y hospitalarias de los SESA que contaron con muestras probabilísticas de representatividad estatal. Las muestras de las unidades ambulatorias se seleccionaron mediante estratificación por nivel de atención y por condición de pertenencia a la red de servicios del SPS. RESULTADOS: Los hallazgos indican que el porcentaje de recetas completamente surtidas ha mejorado en las unidades ambulatorias de los SESA, sobre todo en aquellas que ofrecen servicios a los afiliados al SPS y que alcanzan porcentajes de casi 90 por ciento. Estos porcentajes, sin embargo, siguen siendo inferiores a los de las unidades ambulatorias de las instituciones de seguridad social. Los porcentajes de recetas surtidas en las unidades hospitalarias de los SESA también han mejorado, pero siguen siendo relativamente bajos. En casi todas las entidades federativas, conforme se ha incrementado el porcentaje de surtimiento completo de recetas, ha aumentado la satisfacción de los usuarios con el acceso a los medicamentos. CONCLUSIONES: En 2006, más de 50 por ciento de las entidades federativas presentaron altos niveles de surtimiento completo de recetas entre los afiliados al SPS (>90 por ciento). El mayor problema en este sentido se encuentra en los hospitales, ya que sólo 44 por ciento de los usuarios que recibieron una prescripción en los hospitales de los SESA en 2006 obtuvieron el surtimiento completo de sus recetas. Este hallazgo obliga a revisar la política de medicamentos del SPS, que ha privilegiado...

OBJECTIVE: Measure and compare the percentage of prescriptions fully dispensed to persons with and without Popular Health Insurance (SPS in Spanish) who use ambulatory and general hospital services associated with the Mexico State Health Services (SESA in Spanish), and taking into account insurance status. SESA user satisfaction was also measured with respect to access to medication. MATERIAL AND METHODS: Information for the study was taken from four surveys of SESA ambulatory and hospital units that included probabilistic samples with state representativity. Samples of ambulatory units were selected by stratification according to level of care and association to the SPS service network. RESULTS: The findings indicate that the percentage of prescriptions fully dispensed in SESA ambulatory units has improved, reaching approximately 90 percent, especially among those units offering services to persons affiliated with SPS. Nevertheless, these percentages continue to be lower than those of ambulatory units associated with social security institutions. Percentages of prescriptions fully dispensed have also improved in SESA hospital units, but continue to be relatively low. In nearly all states, as the percentage of prescriptions fully dispensed has increased, user satisfaction with access to medication has also improved. CONCLUSIONS: In 2006 more than 50 percent of the states had high levels of fully dispensed prescriptions among persons with SPS (>90 percent). The more significant problem exists among hospitals, since only 44 percent of users who received a prescription in SESA hospitals in 2006 had their prescriptions fully dispensed. This finding requires a review of SPS medication policies, which have favored highly prescribed low-cost medications at ambulatory services at the expense of higher cost and more therapeutically effective medications for hospital care, the latter having a greater impact on household budgets.

Programas de benefício farmacêutico privados no Brasil e Estados Unidos: uma análise comparativa / Private pharmaceutical benefit programs in Brazil and the United States: a comparative analysis

Esta tese analisa os programas de benefício farmacêutico (PDF's) pelas operadoras de saúde suplementar no Brasil e nos planos de saúde privados americanos. O estudo se desenvolveu a partir de 3 capítulos principais. No primeiro capítulo foi elaborado um modelo que permitisse a comparação entre os diversos PBF's praticados no Brasil e nos Estados Unidos. Para tal foram analisadas as seguintes variáveis: características operacionais dos PBF's; o Sistema de Informação, como uma ferramenta importante para gerenciamento do programa; a adesão ao tratamento e as ferramentas destinadas ao controle se custo e fraude. No segundo capítulo foram analisadas as mudanças recentes ocorridas no mercado americano e as implicações sobre os PBF's e sobre o mercado farmacêutico. Foram avaliadas as formas de disponibilização de medicamentos, com destaque para o surgimento e consolidação das empresas de gerenciamento dos PBF's (PBM's). As ferramentas de controle de custo e farude aplicadas, bem como o impacto da não adesão e as iniciativas no gerenciamento de doentes crônicos. No terceiro capítulo foram analisadas as mudanças pelas quais vem passando o sistema de saúde suplementar no Brasil, foram obtidas informações acerca das iniciativas que vêm sendo praticadas no setor. No final do trabalho foi observado que os PBF's, apesar de recentemente consolidados no mercado americano, são praticados pela grande maioria dos planos privados deste país, com grande impacto sobre o mercado farmacêutico, que viu seu faturamento quase que dobrar em uma década. No Brasil, as iniciativas ainda são esparsas e fragmentadas, sobretudo pela transição que ainda passa o nosso sistema de saúde suplementar. Entretanto, ainda que os PBF's fossem uma prática usual, acreditamos que eles teriam pouco impacto sobre mercado e/ou acesso ao consumo de medicamentos.

Listado de prestaciones médico quirúrgicas, medio de apoyo diagnóstico, medicamentos y exclusiones para la cobertura del seguro de enfermedad maternidad / Surgical medical listing of benefits, half of support diagnosis, medications and exclusions for the covering of the insurance of illness maternity

El Instituto Nicaraguense de Seguridad Social (INSS) da a conocer a los asegurados y sus beneficiarios los beneficios y prestaciones como objeto de cobertura a las que tienen derecho. Este documento es un instrumento técnico de fácil manejo y aplicación por parte de las Empresas Medicas Previsionales y el personal de estas en la aplicación, manejo y prescripción de los medicamentos a los derecho habientes. El presente listado se complementa con el listado Oficial de Medicamentos del Seguro Social de enfermedad Maternidad, y describe las enfermedades y los medios de apoyo diagnóstico a los cuales tienen derecho los asegurados en estado de embarazo, el parto mismo y el puerperio y los hijos de éstos hasta los seis años de edad.

Usefulness of PC communications for medical information

BACKGROUND: A good deal of medical information is in circulation with the great advances in communication technology. This study sought to collect and classify a wide variety of data in circulation, to determine the effects of this medical information via PC on people, to see whether people feel that it is useful, and how it can be applied clinically. METHODS: Contents of medical information in circulation were classified and analyzed from domestic PC network including Chollian, Hitel, and Unitel. The survey was conducted with 700 subjects who were given medical counsel through above communicatian networks between August 1 and September 30, 1997. They were given questionnaires for usefulness of medical information via e-mail and among these, cross-sectional study was made with 336 respondents who were feasible for statistical analysis. RESULTS: Users of medical information currently in circulation can be roughly classified into general and professional ones. Information for general user can be grouped by its contents into one for medical common sense, medical consultation, First Aid, self-diagnasis, medical insurance, drug therapy, medical test interpretation, guide information for hospital and clinic visitors. The survey showed the following responsesn: PC communication was useful(70.8%), its education efficacy was higher than other measures(62.3%), it helped for the prevention of diseases(59.8%), it was useful in the reduction of medical fee (71.4%), I'll get the web information even if charged(63.1%), it helped for the correction of mistaken medical common sense(58.8%), it helped for the understanding of medical service in a hospital(63.5%). CONCLUSIONS: Practically, PC communication can provide general users medical information in a convenient and useful way. In addition, this information can be helpful in the reduction of medical fee and prevention of diseases, and more effective in patient education than other measures.