Custo-efetividade da vacina contra influenza quadrivalente baseada em células comparada com a trivalente baseada em ovo do Programa Nacional de Imunizações brasileiro / Cost-effectiveness of cell-based quadrivalent versus egg-based trivalent influenza vaccination in the Brazilian National Immunization Program

Objetivos: Este estudo teve como objetivo avaliar desfechos clínico-econômicos associados à vacina contra influenza quadrivalente baseada em células (QIVc) versus a vacina trivalente atualmente utilizada (TIVe) para prevenção sazonal de influenza no Programa Nacional de Imunizações (PNI) brasileiro. Métodos: Um modelo estático de árvore de decisão foi usado. Considerou-se um total de 54.071.642 indivíduos vacinados em 2019; a circulação de influenza por subtipo foi baseada em dados de vigilância epidemiológica. A efetividade da vacina (EV) TIVe foi extraída de metanálises publicadas; já a EV relativa da QIVc foi retirada de um estudo observacional retrospectivo. A incompatibilidade antigênica da vacina com vírus circulantes foi baseada em fontes retrospectivas internacionais. O uso de recursos baseou-se em estudos do mundo real. Custos unitários foram retirados de tabelas-padrão publicados em 2019 em reais (BRL). Resultados: Substituir a TIVe pela QIVc pode evitar, anualmente, casos sintomáticos (452.065) e reduzir visitas ambulatoriais (118.735), hospitalizações (15.466), mortes (2.753), custos médicos (-BRL 46.677.357) e custos indiretos (-BRL 59.962.135). O número anual de anos de vida ajustados por qualidade de vida (QALYs) pode aumentar em 96.129. Resultados de base a partir da perspectiva do pagador mostram uma razão de custo-efetividade incremental (RCEI) de BRL 17.293/QALY e, da perspectiva da sociedade, o RCEI obtido foi de um ganho de BRL 16.669/QALY. Usando o Produto Interno Bruto (PIB) brasileiro como um limiar (BRL 34.533/QALY), trocar a TIVe pela QIVc no PNI pode ser uma estratégia altamente custo-efetiva. Conclusões: O uso da QIVc pelo PNI tem potencial para ser altamente custo-efetivo tanto da perspectiva do pagador quanto da sociedade

Objectives: This study aimed to estimate health and economic outcomes associated to cell-based quadrivalent influenza vaccine (QIVc) versus current trivalent influenza vaccines (TIVe) for seasonal influenza prevention in the Brazilian National Immunization Program (NIP), from the societal and public payer perspectives. Methods: A 1-year static decision-tree model based on literature was used. 54,071,642 total vaccinated individuals in 2019 were considered; influenza subtype circulation was based on Brazilian epidemiologic data (2009-2019). TIVe vaccine effectiveness (VE) was extracted from a published meta-analysis and QIVc relative VE from an international retrospective observational study. A/H3N2 egg-adaptation and B mismatch to recommended strain were gathered from international retrospective sources. Resource use was obtained from real-world studies. Inputs were adjusted to influenza subtype and multiple age groups with Brazilian literature. Unit costs were retrieved from published standard tables in 2019 Brazilian Reais (BRL). Results: Replacing TIVe with QIVc, can annually avert symptomatic cases (452,065) and reduce outpatient visits (118,735); hospitalizations (15,466), deaths (2,753), overall medical direct costs (-BRL 46,677,357) and indirect costs (-BRL 59,962,135). The annual number of quality-adjusted life-years (QALYs) could be increased by 96,129. Base case results from the payer perspective show an incremental cost-effectiveness ratio (ICER) of BRL 17,293/QALY gained and from the societal perspective the ICER obtained was BRL 16,669/QALY gained. Using the Brazilian Gross Domestic Product (GDP) as a threshold (BRL 34,533/QALY) switching TIVe with QIVc in the NIP can be a highly cost-effective strategy, leading to a high QALY increment and preventing medical and indirect costs. Conclusions: The use of QIVc by the NIP has the potential to be highly cost-effective in the payer and society perspective

Prevalência da percepção e do tratamento da dor e de seus resultados de saúde em diferentes condições do Brasil / Prevalence of pain awareness, treatment, and associated health outcomes across different conditions in Brazil

BACKGROUND AND OBJECTIVES: Pain is a prevalent clinical condition causing tremendous humanistic and economic burden worldwide. With limited research into the impact of pain on health related outcomes in Brazil, the current study examined prevalence of pain conditions, rate of diagnosis and treatment, and potential impact on health outcomes among Brazilian adults. METHOD: Data were collected from the stratified random sample of adults (n = 12,000) in thecross-sectional 2011 National Health and Wellness Survey (NHWS) in Brazil. Respondents reported on sociodemographic information, health-related quality of life (SF-12v2), work productivity and activity impairment (WPAI), comorbid conditions, and healthcare resource use. Comparisons between those reporting pain and no pain (i.e.,neuropathic pain, fibromyalgia, surgery/medical procedure-related pain, or back pain, versus controls without the respective condition; or arthritis, with vs. without experiencing pain) were conducted using Chi-square and t-tests for categorical and continuous variables, respectively. RESULTS: Back pain was the most commonly reported pain condition (12%), followed by fibromyalgia. Among those experiencing the condition neuropathic pain was the most, and back pain the least, commonly diagnosed and treated. Across conditions, to varying degrees, pain vs. no pain was associated with greater comorbid burden, higher resource utilization, and greater impairments in health status and work productivity, with few differences in sociodemographic factors. CONCLUSION: Pain-related conditions were associated with varying awareness and treatment rates among Brazilian adults. Consistent with previous US and European studies, pain was associated with various negative health outcomes. These findings highlight the under-treatment and range of potential sources of pain burden in Brazil.

JUSTIFICATIVA E OBJETIVOS: A dor é uma condição clínica prevalente que gera um fardo humanístico e econômico tremendo em todo o mundo. Tendo em vista os poucos estudos sobre o impacto da dor em resultados de saúde no Brasil, este estudo avaliou a prevalência de condições dolorosas, a taxa de diagnóstico e tratamento, e o possível impacto nos resultados de saúde entre adultos brasileiros. MÉTODO: Os dados foram coletados de uma amostra estratificada e aleatória de adultos (n = 12.000) da pesquisa transversal National Health and Wellness Survey de 2011 feita no Brasil. Os entrevistados deram informações sociodemográficas, sobre qualidade de vida relacionada à saúde (SF-12v2), produtividade no trabalho e prejuízo de suas atividades (WPAI), condições comórbidas e uso de recursos de assistência à saúde. As comparações entre os indivíduos com e sem dor (isto é, dor neuropática, fibromialgia, dor relacionada a procedimentos cirúrgicos/médicos, ou lombalgia, versus os controles sem a respectiva condição; ou artrite, com versus sem dor) foram realizadas pelos testes Qui-quadrado e t para variáveis categóricas e contínuas, respectivamente. RESULTADOS: Lombalgia foi a condição dolorosa mais comum (12%), seguida de fibromialgia. Entre os incluídos nessa condição, a dor neuropática foi a mais comumente diagnosticada e tratada, e a lombalgia foi a menos diagnosticada e tratada. Nas diferentes condições, em graus variáveis, dor versus sem dor foi associada a maior fardo comórbido, maior utilização de recursos, e maiores prejuízos ao estado de saúde e à produtividade no trabalho, com poucas diferenças nos fatores sociodemográficos. CONCLUSÃO: As condições dolorosas foram associadas a diferentes percepções e taxas de tratamento entre adultos brasileiros. Corroborando estudos anteriores norte-americanos e europeus, a dor foi associada a vários resultados negativos para a saúde. Esses achados destacam o subtratamento e uma gama de fontes potenciais de fardo da dor no Brasil.

Direct medical costs of treating Mexican children under 2 years of age with respiratory syncytial virus

Background. Respiratory syncytial virus (RSV) is the most frequent etiologic agent causing lower respiratory tract infection in children <2 years of age. Between 0.5 and 3% of patients will require hospitalization. The aim of this study was to estimate the direct medical cost of treating children <2 years old with suspicion of RSV at the Instituto Mexicano del Seguro Social (IMSS). Methods. Direct medical costs were estimated from an institutional perspective. Medical records were reviewed from patients <2 years of age who attended emergency services in second-level hospitals including subjects who required hospitalization. Estimated costs were obtained with the microcosting technique using the institutional costs from IMSS (year 2010). Costs were reported in USD (year 2011). Results. When analyzing total medical costs, outpatient management yielded a cost of $230.0 ± $10.30 U.S. dollars (USD), whereas hospitalized patients exhibited an average cost of $8,313.20 ± $595.30 USD. The main components of outpatient management costs were emergency visits, specialist consultations and diagnostic testing (41.6%, 32.7% and 10.7% of the total cost, respectively). In the case of hospitalized patients, intensive care unit cost (89.3%) and overall hospitalization cost (6.5%) represented 95.7% of the total cost. Conclusions. RSV is a disease that represents a significant economic burden for health care institutions, although most patients are treated on an outpatient basis.

Tratamiento antimicótico empírico de pacientes inmunocomprometidos con neutropenia y fiebre persistente con sospecha de aspergilosis sistémica: análisis de costo-efectividad en México / Empirical anti-mycotic treatment of immunocompromised patients with neutropenia and persistent fever with suspicion of systemic aspergillosis: Cost-effectiveness study in Mexico

Introducción. Las micosis sistémicas generan un gran incremento en los costos de la atención médica. Se evaluó el medicamento más costo-efectivo para el tratamiento empírico de aspergilosis sistémica entre la anfotericina B, caspofungina y voriconazol en pacientes con fiebre persistente y neutropenia. Métodos. Modelo tipo árbol de decisiones para estimar los resultados clínicos esperados y los costos asociados del tratamiento de la aspergilosis sistémica. La perspectiva del estudio fue la del proveedor de servicios públicos de salud (Instituto Mexicano del Seguro Social [IMSS]). Temporalidad: 12 semanas. Medida de efectividad: tasa de remisión completa de la infección micótica. Se desarrollaron análisis de sensibilidad univaridos y probabilísticos. Resultados. Los costos totales promedio por paciente esperados para el tratamiento empírico de aspergilosis resultaron convoriconazol en $57 378.58 US; $72 833.96 US con anfotericina B, y de $49 962.37 US con caspofungina. La tasa de remisión total sin eventos adversos fue de 37% para caspofungina, 43.6% para voriconazol y de 51.1% para anfotericina B. El análisis de sensibilidad probabilístico muestra que voriconazol sería el tratamiento más costo-efectivo en 65% de los casos, independientemente de la disposición a pagar por el IMSS. Conclusiones. Los resultados presentados concuerdan con la afirmación de que el tratamiento estándar de primera línea recientemente propuesto para el tratamiento empírico de aspergilosis sistémica debe ser voriconazol.

Introduction. Systemic mycosis has a great impact on medical care costs. The objective of this study was to assess the most cost-effective empirical treatment for systemic aspergillosis, evaluating amphotericin B, caspofungin and voriconazole in patients with persistent fever and neutropenia. Methods. A decision-tree model was used to estimate expected clinical results and costs associated with the treatment for systemic aspergillosis. The study used a healthcare payer's perspective (Mexican Institute of Social Security, IMSS). Time frame was 12 weeks. Effectiveness measure was complete remission of mycotic infection. One-way and probabilistic sensitivity analyses were performed. Results. Average total expected costs per patient for the voriconazole treatment were US $57 378.58, for amphotericin B US $72 833.96, and for caspofungin were US $49 962.37. Thetotal expected remission rate without any adverse events was 37% for caspofungin, 43.6% for voriconazole and 51.1% for amphotericin B. Probabilistic sensitivity analysis showed that voriconazole would be a cost-effective treatment with 65% confidence, regardless of the willingness to pay the IMSS. Conclusions. The results of the study agree with the recommendation that voriconazole must be the empirical treatment for systemic aspergillosis, proposed as a standard first-line antifungal drug.

El concepto de willingness-to-pay en tela de juicio: [revisión] / The willingness-to-pay concept in question: [review]

La idoneidad del concepto de willingness to pay (disponibilidad a pagar) es revisado en las evaluaciones económicas que se realizan en el campo de la salud. Por un lado, existe dentro de la literatura económica un número importante de investigadores que señalan los múltiples problemas metodológicos que entrañan las estimaciones de willingness to pay. Por otro lado, aún el debate teórico-conceptual acerca de la agregación de las preferencias individuales dentro de una demanda agregada no ésta del todo resuelto. Sin embargo, durante los últimos 20 años la estimación de la disponibilidad a pagar dentro de las investigaciones económicas ha aumentado de forma significativa, siendo en muchos casos uno de los principales factores de la toma de decisión en políticas de salud. Plantease alguna de las limitaciones de esta técnica, así como el posible efecto distorsionador que podría tener sobre las evaluaciones económicas que se realizan en el área de la economía de la salud.

The adequacy of the concept of willingness to pay within health economics evaluations is reviewed. A considerable number of researchers in the literature have pointed out multiple methodological issues involving willingness-to-pay estimates. On the other hand, the theoretical discussion about the aggregation of individual preferences within an aggregate demand remains open. However, over the last 20 years, willingness-to-pay estimates alongside health economics research significantly increased and in many cases they are one of the key factors for decision making on issues of health policies. The article describes some limitations of this approach as well as the potential distorting effect that it might have on health economics evaluations.

São revisadas as limitações do uso do conceito de willingness to pay (disposição a pagar) nas avaliações econômicas que se realizam no campo da saúde. Há na literatura econômica muitos investigadores que assinalam os múltiplos problemas metodológicos inerentes às estimações de willingness to pay. Por outro lado, o debate teórico-conceitual acerca da agregação das preferências individuais dentro de uma demanda agregada não está totalmente resolvido. Contudo, durante os últimos 20 anos, a estimação da disposição a pagar calculada pelos estudos tem aumentado de forma significativa, sendo em muitos casos um dos principais fatores de tomada de decisão em políticas de saúde. São apresentadas algumas das limitações desta técnica, assim como o possível efeito de distorção que poderia ter sobre as avaliações econômicas em saúde.

El costo de las principales enfermedades reumáticas inflamatorias desde la perspectiva del paciente en México / Social costs of the most common inflammatory rheumatic diseases in Mexico from the patient's perspective

Objetivo: Estimar el costo de la artritis reumatoide (AR), la espondilitis anquilosante (EA) y la gota, desde la perspectiva del paciente. Métodos: Análisis transversal de los costos y utilización de recursos de 690 pacientes con AR, EA y gota, de 10 departamentos de centros hospitalarios y consultorios privados de cinco ciudades del país, al momento de ser incluidos en una cohorte dinámica. Se incluye una estimación de los gastos de bolsillo, los costos médicos directos institucionales y el costo médico directo real. Resultados: El gasto de bolsillo promedio (SD) anual (en dólares) en pacientes con AR ascendió a $610.0 ($302.2), en EA a $578.6 ($220.5) y en gota a $245.3 ($124.0), lo que equivalió a 15, 9.6 y 2.5% del ingreso familiar, respectivamente. El gasto de bolsillo representó 26.1% del costo total anual por paciente con AR, 25.3% con EA y 24.4% con gota. Los costos directos institucionales esperados por paciente/año con AR fueron de $1724.2, con EA de $1710.8 y con gota de $760.7. El costo total anual por paciente con AR fue de $2334.3, con EA de $2289.4 y con gota de $1006.1. Los componentes del gasto de bolsillo de mayor cuantía fueron los medicamentos, exámenes de laboratorio y gabinete y las terapias alternativas. Conclusiones: Se concluye que desde la perspectiva del paciente, el costo de la AR, EA y gota equivale a la cuarta parte del costo médico directo. La AR es la enfermedad que mayor gasto implica.

OBJECTIVE: To estimate the social costs of rheumatoid arthritis (RA), ankylosing spondylitis (AS), and gout from the patient's perspective. METHODS: We carried out a cross-sectional analysis of the cost and resource utilization of 690 RA, AS, and gout patients from 10 medical centers and private facilities in five cities of Mexico. The information was obtained from the baseline of a dynamic cohort. We estimated out-of-pocket expenses, institutional direct costs, and direct medical costs. RESULTS: The mean (SD) annual out-of-pocket expense (USD) was $610.0 ($302.2) for RA, $578.6 ($220.5) for AS, and $245.3 ($124.0) for gout. Figures correspond to 15%, 9.6%, and 2.5% of the family income. They also represented 26.1%, 25.3%, and 24.4% of the total annual cost per RA, AS, and gout patients, respectively. The expected direct institutional patient/year costs were 1,724.2 for RA, $1,710.8 for AS, and $760.7 for gout. The total patient annual costs were $2,334.3 for RA, $2,289.4 for AS, and $1,006.1 for gout. Most out-of-pocket expenses were used to purchase drugs, pay for laboratory tests, imaging studies, and alternative therapies. CONCLUSIONS: From the patient's perspective, the cost of RA, AS, and gout represents 25% of direct medical costs. The cost of RA is higher than that for AS and gout.

Competencia en el sector salud: análisis de la reforma sueca (1992 - 1995): [comentarios] / Competitiveness in the health care sector: analysis of the Swedish reform (1992-1995): [comment]

El artículo revisa los éxitos y fracasos de la reforma sueca de salud, así como las lecciones que dejó en su afán de alcanzar mejores resultados financieros y estándares de calidad.

The paper reviews the outcomes and failures of the Swedish health care reform, as well as the lessons learned for accomplishing better financial results and quality standards.

Análisis de costos en tres métodos de esterilización / Cost analysis on three sterilization methods

Introducción: El retraso en las cirugías por falta de instrumental estéril genera altos costos de atención por lo que se requiere información de métodos eficientes de esterilización. Objetivo: Identificar cuál es el método de esterilización más costo-efectivo entre la solución de súper oxidación de Ph neutro (M60), esterilización en Plasma de Peróxido de Hidrógeno y vapor saturado a presión en una unidad quirúrgica. Metodología: Se realizó una evaluación económica completa de tipo costo-efectividad en un hospital de tercer nivel. El cálculo de los costos fijos incluyó el costo de la infraestructura para los tres métodos de esterilización; los costos variables se calcularon para cada ciclo de esterilización y fueron establecidos a través del monitoreo y registro de cargas, personal, material y consumibles de cada método; el costo total se obtuvo con la suma de costos fijos y variables. La medida de efectividad fue el porcentaje de equipos estériles obtenidos en cada método. Para establecer la diferencia entre los grupos se realizó análisis estadístico con una prueba de Chi cuadrada. Resultados: El costo por carga promedio de esterilización con vapor fue de $1,049 pesos, con plasma de $6,710.88 pesos y con M60 de $87.50 pesos. El método de plasma obtuvo 95% de equipos estériles, por vapor 95% y por M60 100%. No se encontraron diferencias estadísticamente significativas en la efectividad. Conclusiones: Al no encontrar diferencias en las efectividades, se concluye en un análisis de minimización de costos donde el método de menor costo fue el M60.

Introduction: Delay of surgeries due to lack of sterilized instruments, generates high costs of medical services; therefore it is necessary to establish information regarding efficient methods of sterilization. Objective: To identify the best cost -effective method among 3 different systems: superoxidation of neutral Ph method (M60), plasma of peroxide hydrogen method, and pressure, saturated steam method, in a surgical unit. Methodology: A complete economic evaluation of cost-effectiveness type was done in a hospital of third level. First, a quote of fixed costs included: infrastructure costs for three different methods of sterilization. Secondly, the variable costs were calculated for each cycle of sterilization and were established through monitoring and recording the number of loads, staff, materials, and supplies for each method. Finally, the total cost was equal to the addition of fixed and variable costs. The measurement of effectiveness was the percentage of sterilized equipment by each method. To establish the difference among the groups, a statistic analysis was done through the Square Chi method. Results: The average costs for each load through steam sterilization was S1,049.00 Mexican pesos; with plasma was S6,710.88 Mexican pesos, and with M60 of $87.50 Mexican pesos. The plasma method obtained 95% of sterilized equipments, steam 95%, and M60 100%. None significant statistic difference for effectiveness was found. Conclusion: As no effectiveness differences were found, the analysis of minimized costs was concluded that the method M60 showed to be the less expensive.