Catastrophic health expenditure and multimorbidity among older adults in Brazil / Gastos catastróficos em saúde e multimorbidade entre adultos mais velhos no Brasil

ABSTRACT OBJECTIVE: To estimate the relation between catastrophic health expenditure (CHE) and multimorbidity in a national representative sample of the Brazilian population aged 50 year or older. METHODS: This study used data from 8,347 participants of the Estudo Longitudinal de Saúde dos Idosos Brasileiros (ELSI - Brazilian Longitudinal Study of Aging) conducted in 2015-2016. The dependent variable was CHE, defined by the ratio between the health expenses of the adult aged 50 years or older and the household income. The variable of interest was multimorbidity (two or more chronic diseases) and the variable used for stratification was the wealth score. The main analyses were based on multivariate logistic regression. RESULTS: The prevalence of CHE was 17.9% and 7.5%, for expenditures corresponding to 10 and 25% of the household income, respectively. The prevalence of multimorbidity was 63.2%. Multimorbidity showed positive and independent associations with CHE (OR = 1.95, 95%CI 1.67-2.28, and OR = 1.40, 95%CI 1.11-1.76 for expenditures corresponding to 10% and 25%, respectively). Expenditures associated with multimorbidity were higher among those with lower wealth scores. CONCLUSIONS: The results draw attention to the need for an integrated approach of multimorbidity in health services, in order to avoid CHE, particularly among older adults with worse socioeconomic conditions.

RESUMO OBJETIVO: Estimar a relação entre gasto catastrófico em saúde (GCS) e multimorbidade em amostra nacional representativa da população brasileira com 50 anos de idade ou mais. MÉTODOS: Foram utilizados dados de 8.347 participantes do Estudo Longitudinal da Saúde dos Idosos Brasileiros (2015-2016). A variável dependente foi o GCS, definido pela razão entre as despesas com saúde do adulto de 50 anos ou mais e a renda domiciliar. A variável de interesse foi a multimorbidade (duas ou mais doenças crônicas), e a variável utilizada para estratificação foi o escore de riqueza. As principais análises foram baseadas na regressão logística multivariada. RESULTADOS: A prevalçncia de GCS foi de 17,9% e 7,5% para gastos correspondentes a 10% e 25% da renda domiciliar, respectivamente. A prevalçncia da multimorbidade foi de 63,2%. A multimorbidade apresentou associações positivas e independentes com GCS (OR = 1,95, IC95% 1,67-2,28 e OR = 1,40, IC95% 1,11-1,76 para gastos correspondentes a 10% e 25%, respectivamente). Os gastos associados à multimorbidade foram maiores entre aqueles com menor escore de riqueza. CONCLUSÕES: Os resultados chamam atenção para a necessidade de uma abordagem integrada da multimorbidade nos serviços de saúde, de forma a evitar os GCS, particularmente entre adultos mais velhos com piores condições socioeconômicas.

Las dimensiones económicas de las enfermedades no transmisibles en América Latina y el Caribe

En la presente obra también se aprovechan las evidencias previas y se evalúan las investigaciones empíricas más recientes con la finalidad de influir en la formulación de políticas, la preparación de programas y la asignación de recursos en torno a las ENT en los planos regional y nacional. Esta publicación también recomienda medidas específicas y hace un llamado a la participación de toda la sociedad en el manejo de las ENT como un problema económico urgente y un obstáculo al desarrollo. Con estos objetivos en mente se redactó. Las dimensiones económicas de las enfermedades no transmisibles en América Latina y el Caribe, fruto de la labor de asesores técnicos de la OPS y de muchos otros expertos en el tema. La obra está dirigida a un auditorio variado que comprende desde académicos y profesionales de la salud hasta formuladores de políticas y directores de programas, así como medios de comunicación, legisladores y público en general.

Concepto carga en los modelos teóricos sobre enfermedad crónica: revisión sistemática / Charging concept theoretical models diseasechronic: a systematic review

RESUMEN Objetivo Describir el abordaje de carga que tienen los modelos teóricos sobre enfermedad crónica no trasmisible (ECNT) Metodología La búsqueda de los estudios se realizó definiendo la ventana de observación bajo criterios establecidos para los descriptores modelos teóricos, enfermedad crónica y costo de la enfermedad, en 14 bases de datos como Scielo, Medline, Science direct, Infotrac Health Reference Center Academic, teniendo en cuenta publicaciones arbitradas e incluyendo publicaciones cuantitativas, cualitativas y de revisión, tiempo e idioma de las publicaciones y tipo de estdio tal como se presentan a contiuación. Resultados Las 20 publicaciones registradas van desde el 2005 al 2012. Dentro de ellas aparecen tres grupos para el abordaje de la carga que incluyen el que se basa en un paradigma de cuidado, el que la entiende como un paradigma económico conjunto de la enfermedad y su impacto financiero y los paradigmas eclécticos que admiten la suma de miradas de algunos matices económicos junto con otros propios de la experiencia de vivir o cuidar en situaciones de ECNT. Conclusiones Los modelos teóricos sobre enfermedad crónica evidenciados indican que el concepto se agrupa en tres: la carga vista desde el abordaje del cuidado; el abordaje económico centrado en la enfermedad y su impacto financiero y el abordaje mixto que retoma parcialmente aspectos de los dos anteriores. La comparación de estos hallazgos con la literatura ratifica los grupos encontrados y sugiere la necesidad de hacer explícito el concepto de carga de la ECNT desde el paradigma empleado.(AU)

ABSTRACT Objective To describe the approach of cost of illness within the theoretical models of chronic non communicable disease (NCD) Methodology A systematic literature review was carried by defining observational parameters guided by the key words "theoretical, models" , "chronic disease" and "cost of illness" in 14 databases as Scielo, Medline, Science direct, Infotrac Health Reference Center Academic, including indexed publications of quantitative, qualitative, analysis and review articles, their publication language with an open time definition. Results 20 registered publications were found ranging from 2005 to 2012. Within these publications three groups emerged in the way they approach the burden or illness cost. They include: a group based on a caring paradigm, a group based on an economic paradigm understood as a set of the disease appear and their financial impact and a third group that with an eclectic approach that combined some of the economic aspects as well as some of the experiences of living and caring in situations of NCDs. Conclusions The theoretical models of chronic disease evidenced by this systematic search indicates that the concept of cost of illness is grouped into three: the view from the approach of burden of care; the economic approach focused on the disease and its financial impact and the mixed approach that takes aspects of the previous two. Comparing these findings with the literature confirms the groups founded and suggested the need to make explicit the utilized paradigm within in the conceptualization of the cost of illness while approaching NCDs.(AU)

Chronic case management: Clinical governance with cost reductions / Gerenciamento de casos crônicos: governança clínica com redução de custos

SUMMARY Introduction: With increasing global impact of chronic degenerative non-communicable diseases (CDNCD), multidisciplinary chronic disease management care programs (CDMCP) come as a solution to improve the quality of patients care. Method: We conducted a cross-sectional epidemiologic prospective cohort study with data comparing a group of patients monitored by a CDMCP with subjects without CDMCP care, from 2010 to 2012. The patients monitored in this program were selected because they presented CDNCD with frequent hospitalization and/or emergency care in the year prior to study selection. Also, the patients could be referred to the program by their physicians and/or other programs such as HomeCare or family medicine. All costs related to the program were included and compared with the costs of users with the same epidemiological profile who opted for not participating in the CDMCP. Results: We analyzed data from 1,256 cases, including 639 (51%) men and 617 (49%) women. The mean age was 56.99 years and 73% were older than 50 years. There was a prevalence of 34% (428) cases with ischemic heart disease (myocardial infarction and stroke) and 17% (210) with neoplasms. The cases studied showed a reduction of 79% in the number of days of hospitalization compared with the cases without CDMCP monitoring. The average reduction of total costs (hospitalizations, emergency room visits and/or disease complications) was 31.94%, with average reduction of 8.36% in monthly costs. Conclusion: Multidisciplinary monitoring carried out by CDNCD patient management programs can reduce hospitalizations, emergency room visits and complications, positively impacting the costs with health care.

RESUMO Introdução: com o crescente impacto mundial das doenças crônico-degenerativas não transmissíveis (DCDNT), os programas multidisciplinares de gerenciamento de pacientes com doenças crônicas (PGDC) apresentam-se como uma solução para melhorar a qualidade do atendimento prestado. Método: foi realizado um estudo epidemiológico, tipo coorte, prospectivo, com dados comparando um grupo em acompanhamento em um PGDC com um grupo sem esse acompanhamento, no período de 2010 a 2012. Usuários acompanhados pelo programa eram selecionados por serem portadores de DCDNT, com internamentos e/ou consultas em serviços de emergência frequentes no ano anterior à seleção; por indicação do médico assistente e/ou outros programas como HomeCare ou medicina da família. Foram contabilizados todos os custos relacionados com assistência em saúde do programa e comparados com os custos de usuários com mesmo perfil epidemiológico que optaram pelo não acompanhamento no programa. Resultados: foram selecionados dados de 1.256 casos, sendo 639 (51%) do sexo masculino e 617 (49%) mulheres. A média etária foi de 56,99 e 73% dos casos acima dos 50 anos. Predomínio de 34% (428) de casos de doenças cardiovasculares isquêmicas (infarto do miocárdio e acidente vascular cerebral) e 17% (210) de neoplasias. Os casos acompanhados apresentaram redução de 79% dos dias de internamento em comparação com casos não acompanhados. A redução média de custos totais (internamentos, consultas de emergência e/ou complicações) foi de 31,94%, com redução média mensal de custos de 8,36%. Conclusão: acompanhamento multidisciplinar em programa de gerenciamento de pacientes portadores de DCDNT pode reduzir internamentos, consultas de emergência e complicações, impactando positivamente nos custos da assistência à saúde.

Bacaba beverage produced by Umutina Brazilian Amerindians: Microbiological and chemical characterization

Bacaba chicha is a beverage prepared by the indigenous Umutina people from the bacaba fruit (Oenocarpus bacaba), a purple berry that is rich in fat and carbohydrates, as well as a source of phenolic compounds. In this study, samples of bacaba chicha beverage were collected, and the microbial community was assessed using culture-dependent and -independent techniques. The nutritional composition and metabolite profiles were analyzed, and species belonging to lactic acid bacteria (LAB) and yeasts were detected. The LAB group detected by culture-dependent analysis included Enterococcus hormaechei and Leuconostoc lactis. Polymerase chain reaction and denaturing gradient gel electrophoresis (PCR-DGGE) detected additional Propionibacterium avidum, Acetobacter spp., and uncultured bacteria. Pichia caribbica and Pichia guilliermondii were detected in a culture-dependent method, and Pichia caribbica was confirmed by PCR-DGGE analysis. The pH value of the beverage was 6.2. The nutritional composition was as follows: 16.47 ± 0.73 g 100 mL-1 dry matter, 2.2 ± 0.0 g 100 mL-1 fat, 3.36 ± 0.44 g 100 mL-1 protein, and 10.87 ± 0.26 g 100 mL-1 carbohydrate. The metabolites detected were 2.69 g L-1 succinic acid, 0.9 g L-1 acetic acid, 0.49 g L-1 citric acid, 0.52 g L-1 ethanol, and 0.4 g L-1 glycerol. This is the first study to identify microbial diversity in bacaba chicha spontaneous fermentation. This study is also the starting step in the immaterial record of this Brazilian indigenous beverage prepared from bacaba fruit.

Caracterización de la población urbana y factores de riesgo en el municipio de Guaimaca, Honduras / Characterization of the urban population and risk factors, Municipality of Guaimaca, Honduras

El análisis de la situación de salud como proceso, tiene como característica principal la interrelación de variables pertenecientes al aspecto político, socioeconómico y ecológico de la comunidad, que permite generar una descripción y explicación del proceso salud enfermedad. Objetivo: Identificar las características de la estructura poblacional y los factores de riesgo de las personas del área urbana del municipio de Guaimaca, Francisco Morazán, de noviembre 2012 a noviembre de 2013. Material y Métodos: Estudio descriptivo de corte transversal. La población fue de 12,442 personas de ambos sexos de todas las edades. Se utilizó para la recolección de datos la ficha familiar conformada por 43 ítems y se elaboró un instructivo que facilitó el llenado de la ficha. Resultados: La morbilidad mayor de 15 días de duración presente en la población, mostró que las primeras causas de enfermedad son: hipertensión arterial 5.2%; diabetes mellitus 1.7% y asma bronquial 1.3%. En el grupo de personas aparentemente sanas no se encontró diferencia por sexo; en el grupo de población con riesgo predominó el sexo masculino 21%. En el grupo población enferma predominó el femenino con 11.6%; en las personas con deficiencia, incapacidad o secuela no se encontró diferencia porcentual. Conclusión. En el área urbana del municipio de Guaimaca la mayoríade las personas resultaron estar aparentemente sana. Los grupos dispensariales II, III y IV estaban presentes en la población en menor frecuencia...(AU)

Burden of physical inactivity and hospitalization costs due to chronic diseases / Impacto da inatividade física e custos de hospitalização por doenças crônicas

OBJECTIVE To evaluate the physical inactivity-related inpatient costs of chronic non-communicable diseases. METHODS This study used data from 2013, from Brazilian Unified Health System, regarding inpatient numbers and costs due to malignant colon and breast neoplasms, cerebrovascular diseases, ischemic heart diseases, hypertension, diabetes, and osteoporosis. In order to calculate the share physical inactivity represents in that, the physical inactivity-related risks, which apply to each disease, were considered, and physical inactivity prevalence during leisure activities was obtained from Pesquisa Nacional por Amostra de Domicílio (Brazil's National Household Sample Survey). The analysis was stratified by genders and residing country regions of subjects who were 40 years or older. The physical inactivity-related hospitalization cost regarding each cause was multiplied by the respective share it regarded to. RESULTS In 2013, 974,641 patients were admitted due to seven different causes in Brazil, which represented a high cost. South region was found to have the highest patient admission rate in most studied causes. The highest prevalences for physical inactivity were observed in North and Northeast regions. The highest inactivity-related share in men was found for osteoporosis in all regions (≈ 35.0%), whereas diabetes was found to have a higher share regarding inactivity in women (33.0% to 37.0% variation in the regions). Ischemic heart diseases accounted for the highest total costs that could be linked to physical inactivity in all regions and for both genders, being followed by cerebrovascular diseases. Approximately 15.0% of inpatient costs from Brazilian Unified Health System were connected to physical inactivity. CONCLUSIONS Physical inactivity significantly impacts the number of patient admissions due to the evaluated causes and through their resulting costs, with different genders and country regions representing different shares.

OBJETIVO Avaliar o custo de internações por doenças crônicas não transmissíveis atribuível à inatividade física. MÉTODOS Este estudo utilizou dados de 2013, do Sistema Único de Saúde, referentes ao número e respectivo custo das internações por neoplasia maligna de cólon e mama, doenças cerebrovasculares, doenças isquêmicas do coração, hipertensão, diabetes e osteoporose. Para o cálculo da fração atribuível à inatividade física foram considerados os riscos relativos da inatividade física a cada doença e a prevalência de inatividade física no lazer foi obtida da Pesquisa Nacional por Amostra de Domicílio. A análise foi estratificada por sexo e região do País de indivíduos com idade igual ou superior a 40 anos. O custo das internações de cada causa atribuível à inatividade física foi multiplicado pela respectiva fração a ela atribuível. RESULTADOS Foram realizadas 974.641 internações hospitalares por sete causas de internações no Brasil, em 2013, o que representou custo alto. A região Sul apresentou a maior taxa de internação na maioria das causas estudadas. A maior prevalência de inatividade física ocorreu nas regiões Norte e Nordeste. A maior fração atribuível à inatividade em homens foi encontrada para a osteoporose em todas as regiões (≈ 35,0%), enquanto o diabetes apresentou maior fração atribuível à inatividade em mulheres (variação de 33,0% a 37,0% nas regiões). As doenças isquêmicas do coração foram responsáveis pelos mais altos custos totais e atribuíveis à inatividade física em todas as regiões e em ambos os sexos, seguidas das doenças cerebrovasculares. Aproximadamente 15,0% dos custos ao Sistema Único de Saúde das internações foi atribuível à inatividade física. CONCLUSÕES A inatividade física impacta significativamente o número de internações hospitalares pelas causas avaliadas e nos custos resultantes, com diferenças na ocorrência dependendo do sexo e região do País.

Evidence of a Broken Healthcare Delivery System in Korea: Unnecessary Hospital Outpatient Utilization among Patients with a Single Chronic Disease Without Complications

This study aims to estimate the volume of unnecessarily utilized hospital outpatient services in Korea and quantify the total cost resulting from the inappropriate utilization. The analysis included a sample of 27,320,505 outpatient claims from the 2009 National Inpatient Sample database. Using the Charlson Comorbidity Index (CCI), patients were considered to have received 'unnecessary hospital outpatient utilization' if they had a CCI score of 0 and were concurrently admitted to hospital for treatment of a single chronic disease - hypertension (HTN), diabetes mellitus (DM), or hyperlipidemia (HL) - without complication. Overall, 85% of patients received unnecessary hospital services. Also hospitals were taking away 18.7% of HTN patients, 18.6% of DM and 31.6% of HL from clinics. Healthcare expenditures from unnecessary hospital outpatient utilization were estimated at: HTN (94,058 thousands USD, 38.6% of total expenditure); DM (17,795 thousands USD, 40.6%) and HL (62,876 thousands USD, 49.1%). If 100% of patients who received unnecessary hospital outpatient services were redirected to clinics, the estimated savings would be 104,226 thousands USD. This research proves that approximately 85% of hospital outpatient utilizations are unnecessary and that a significant amount of money is wasted on unnecessary healthcare services; thus burdening the National Health Insurance Service (NHIS) and patients.

Impacto de los trastornos psiquiátricos comunes y las condiciones crónicas físicas en el individuo y la sociedade / The impact of common mental and physical health conditions on days out of role: costs for the individual and society

OBJETIVO: Estimar los costos individuales y poblacionales de condiciones crónicas físicas y mentales comunes en la población mexicana, en función del número de días perdidos por problemas en el funcionamiento. MATERIAL Y MÉTODOS: 5 826 adultos fueron evaluados entre 2001-2002 con la Entrevista Internacional Psiquiátrica Compuesta y el Cuestionario para la Evaluación de Discapacidades. Se realizaron modelos generales lineales y se estimó la proporción de riesgo atribuible a la población, tomando en cuenta la prevalencia de la condición y la comorbilidad. RESULTADOS: Las condiciones de mayor impacto para el individuo son la depresión, el estrés postraumático y el trastorno bipolar. Las de mayor impacto a nivel poblacional son la depresión, el dolor, el insomnio y las enfermedades cardiovasculares. CONCLUSIÓN: Los hallazgos señalan la importancia de aumentar el gasto en salud mental para asignar una proporción más equitativa para su atención en cuanto al costo que representan para la sociedad.

OBJECTIVE: To estimate the individual and societal costs of common mental and physical health conditions in the Mexican population with regards to the number of days out of role. MATERIALS AND METHODS: 5 826 adults were evaluated in 2001-2002 with the Composite International Diagnostic Interview and the WHO Disability Assessment Schedule. General linear models were used to estimate individual-level effects. Societal-level effects were estimated with the population attributable risk proportion which takes into account prevalence and comorbidity of disorders. RESULTS: The conditions with the strongest individual -level effects were major depression, post-traumatic stress disorder and bipolar disorder. The strongest societal-level effects were associated with major depression, pain, insomnia and cardiovascular conditions. CONCLUSION: The findings suggest the importance of investing in mental health expenditure to a level commensurate with the costs to society of mental health disorders.

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

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

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

Chronic non-communicable diseases and the economy / Las enfermedades no comunicables crónicas y la economía

There is no question that chronic non-communicable diseases (CNCDs) pose the single, greatest sustained threat to the stability of health systems worldwide. While undoubtedly the main dimension of the CNCDs challenge is in respect of the health and well-being of the population, it is becoming increasingly obvious that CNCDs are also posing a serious challenge to economies. Health system costs are increasing faster than national income in almost all nations and the main cause is the growing incidence of CNCDs and the diverse spill-over effects. The concern is that if this continues, there will come a time when the economic system will simply no longer be capable of coping with the burden of the CNCDs. In these circumstances the economist has two major concerns. The first is to understand and explain how CNCDs affect the functioning of the economic system. It is argued that while the analysis will necessarily begin on the qualitative level, for policy purposes it must also be taken to the quantitative level. The second major concern of the economist is to understand and explain how the working of the economy influences the incidence of CNCDs in particular countries. The author suggests that at a time when the prevention and management of CNCDs are high on the agenda of many nations, it is important to know whether the measures being taken to improve human development and economic well-being are themselves contributing to an increasing incidence of CNCDs particularly in small, vulnerable, open economies. In this regard, this paper briefly explains how CNCDs affect the economic system and presents some of the estimates of quantitative impact on the economy.

No hay duda de que las enfermedades no comunicables crónicas (ENCCs) representan la única y mayor amenaza sostenida para la estabilidad de los sistemas de salud a nivel mundial. Si bien no cabe duda de que la dimensión principal del desafío de las ENCCs se presenta con respecto a la salud y el bienestar de la población, se hace cada vez más obvio que las ENCCs representan también un serio reto para las economías. Los costos del sistema de salud están aumentando más rápidamente que el ingreso nacional en casi todas las naciones y la causa principal es la incidencia creciente de las ENCCs y los diversos efectos de desbordamiento. La preocupación es que si esto continúa, llegará el momento en que el sistema económico simplemente no podrá soportar más la carga de las ENCCs. Según el autor, en estas circunstancias el economista se enfrenta a dos problemas principales. El primero es entender y explicar cómo las ENCCs afectan el funcionando del sistema económico. En este punto, se aduce el argumento de que aunque el análisis tendrá necesariamente que comenzar en el nivel cualitativo, por razones de las políticas a seguir, tendrá que ser llevado también al nivel cuantitativo. El segundo problema principal del economista es entender y explicar cómo el funcionamiento de la economía influye en la incidencia de las ENCCs en países específicos. El autor sugiere que en un momento en que la prevención y el tratamiento de las ENCCs constituyen una prioridad en la agenda de muchos países, es importante saber si las medidas que se están tomando para mejorar el desarrollo humano y el bienestar económico, estén acaso contribuyendo ellas mismas a una creciente incidencia de las ENCCs, especialmente en las economías pequeñas, vulnerables, y abiertas. Al respecto, el autor explica brevemente cómo las ENCCs afectan el sistema económico, y presenta algunos estimados del impacto cuantitativo sobre la economía.

Chronic disease in the Caribbean: strategies to respond to the public health challenge in the region. What can we learn from Jamaica's experience? / Enfermedades crónicas en el Caribe: estrategias para responder a los retos de la salud pública en la región. ¿Qué podemos aprender de la experiencia de Jamaica?

With the advent of the epidemiological transition, chronic non-communicable diseases (CNCDs) have emerged as the leading cause of death globally. In this paper, we present an overview of the burden of CNCDs in the Caribbean region and use Jamaica as a case-study to review the impact of policy initiatives and interventions implemented in response to the CNCD epidemic. The findings show that while Jamaica has implemented several policy initiatives aimed at stemming the tide of the CNCD epidemic, a comparison of data from two national health and lifestyle surveys conducted in Jamaica in 2000/01 and 2007/08 revealed that there was an increase in the prevalence of intermediate CNCD risk factors such as hypertension and obesity. We therefore present recommended strategies which we believe will enhance the current CNCD response and thus reduce, or at least stem, the current epidemic of CNCDs.

Con el advenimiento de la transición epidemiológica, las enfermedades no comunicables crónicas (ENCCs) han emergido como la causa principal de muerte a nivel mundial. En este trabajo, se presenta un panorama general de la carga que las ENCCs representa para la región caribeña. Asimismo, se utiliza Jamaica como estudio de caso para examinar el impacto de las iniciativas en materia de políticas así como las intervenciones, implementadas en respuesta a la epidemia de ENCC. Los hallazgos muestran que si bien Jamaica ha implementado varias iniciativas en cuanto a políticas, dirigidas a detener la marea de la epidemia de ENCC, una comparación de datos de dos encuestas nacionales sobre salud y estilo de vida realizadas en Jamaica en 2000/01 y 2007/08 revelaron que hubo un aumento de la prevalencia de los factores de riesgo intermedios de las ENCC, tales como la hipertensión y la obesidad. Por lo tanto, se presentan estrategias recomendadas, las cuales pueden - a nuestro juicio - mejorar la respuesta actual a las ENCC, y por ende reducir - o al menos frenar - la actual epidemia de ENCCs.

Avaliação econômica das anticitocinas adalimumabe, etanercepte e infliximabe no tratamento da artrite reumatoide no Estado do Paraná / Economic evaluation of anticitokines adalimumab, etanercept and infliximab for treatment of rheumatoid arthritis in Paraná State, Brazil

Este estudo objetivou realizar uma avaliação econômica das anticitocinas adalimumabe (ADA), etanercepte (ETA) e infliximabe (IFX) para o tratamento da artrite reumatoide no Estado do Paraná, sob a perspectiva do SUS. Os dados de eficácia e segurança dos tratamentos foram buscados na literatura, e os custos foram calculados com valores gastos pelo SUS para cada um dos tratamentos. Foi elaborado o modelo de Markov para obter a relação custo-efetividade de cada tratamento. A relação custo-efetividade incremental (ICER) comparado ao tratamento padrão também foi calculada para cada anticitocina. Análises de sensibilidade e taxas de desconto foram aplicadas. Na avaliação custo-efetividade, encontraram-se custos por QALY de R$ 511.633,00, R$ 437.486,00 e R$ 657.593,00 para ADA, ETA e IFX, respectivamente. O ICER por QALY foi R$ 628.124,00, R$ 509.974,00 e R$ 965.927,00 para ADA, ETA e IFX, respectivamente. Nas análises de sensibilidade, o ETA e o ADA apresentaram valores próximos. Cabe aos gestores públicos e aos médicos prescritores a escolha adequada para cada paciente, entre os tratamentos disponibilizados.

This study aimed to perform an economic evaluation of anticytokines adalimumab (ADA), etanercept (ETA) and infliximab (IFX) for the treatment of rheumatoid arthritis in the State of Parana, in Brazil, in the perspective of the Brazilian Unified Health System. Data on efficacy and safety of treatment were collected in literature, and costs were calculated on the amounts spent by the Government for each treatment. A Markov model was performed to get the cost-effectiveness of each treatment. The incremental cost-effectiveness relationship (ICER) compared to a standard treatment was also calculated for each anticytokine. Sensitivity analysis and discount rates were applied. In assessing cost-effectiveness we found the following values (cost at R$ per QALY): 511,633.00, 437,486.00 and 657,593.00 (respectively for ADA, ETA and IFX). The ICER (R$ per QALY) was 628,124.00, 509,974.00 and 965,927.00 (for ADA, ETA and IFX). In the sensitivity analysis, ETA and ADA showed similar values. It is for public managers and physicians the choice for each patient, among the treatments available.

Educación y asma en la escuela: la carga del asma: ausentismo y rendimiento escolar: [revisión] / Education and asthma in school: burden of asthma and truancy school performance: [review]

Asma es la enfermedad crónica más común en la infancia. Sus cifras de incidencia y prevalencia siguen aumentando a nivel mundial a pesar de los nuevos métodos diagnósticos y el arsenal terapéutico específico utilizado para lograr un control adecuado. El fracaso en dicho control depende, en alto grado, del poco conocimiento que tiene el paciente sobre su enfermedad y el tipo de tratamiento que debe realizar para lograrlo. Aun en países con excelentes sistemas de salud y suministro de medicamentos gratuitos, el ansiado control total ha sido difícil de alcanzar y las cifras de personas que manejan bien su asma son decepcionantes. Urge convocar equipos multidisciplinarios de salud, educación, deporte y desarrollo social, de sectores públicos y privados, para la elaboración de políticas públicas efectivas tendientes a enfrentar la gran carga que representa el asma en la economía estadal y doméstica, así como también el deterioro importante en la calidad de vida de quienes la sufren. Los programas de seguimiento y educación sanitaria del asmático y sus cuidadores deben constituir una prioridad para el Estado, quien está encargado de velar, gratuitamente, por el bienestar biopsicosocial de cada uno de sus miembros.

Asthma is the most common chronic disease during childhood. Despite the growing number of methods and techniques employed for diagnosis and medical treatments, asthma keeps growing in number of person who suffer it. Failure to control asthma will depend on the knowledge that the patient has about the disease and the treatment that is given by the medical team. Even in countries with excellent health systems and free supply of, the longed total control has been difficult to reach and the numbers of persons who deal well the disease are disappointing. It is urgent to summon multidisciplinary work teams in health, education, sport and social development in public and private sectors. These efforts should be aimed at the production of effective public policies tending to face the great load that asthma represents for the local and national economy, as well as to alleviate the important deterioration in the quality of life of those who suffer it. The programs of follow-up and sanitary education of the asthmatic patient and his keepers must constitute a priority for the State, who is entrusted to watch, free of cost, over the biopsicosocial well-being of each of his members.

Las enfermedades crónicas no transmisibles en México: sinopsis epidemiológica y prevención integral / Chronic non-communicable diseases in Mexico: epidemiologic synopsis and integral prevention

El gobierno federal desarrolla acciones para reducir la mortalidad por las "enfermedades crónicas no transmisibles" (ECNT). Una de ellas es la creación de unidades médicas de especialidad (Uneme) diseñadas para el tratamiento especializado de las ECNT (sobrepeso, obesidad, riesgo cardiovascular y diabetes). La intervención se basa en la participación de un grupo multidisciplinario entrenado ex profeso, la educación del paciente sobre su salud, la incorporación de la familia al tratamiento y la resolución de las condiciones que limitan la observancia de las recomendaciones. El tratamiento está indicado con base en protocolos estandarizados. La eficacia de la intervención se evalúa en forma sistemática mediante indicadores cuantitativos predefinidos. Se espera que las Uneme resulten en ahorros para el sistema de salud. En suma, este último desarrolla mejores medidas de control para las ECNT. La evaluación del desempeño de las Uneme generará información para planear acciones preventivas futuras.

The federal government has implemented several strategies to reduce mortality caused by chronic non-communicable diseases (CNTD). One example is the development of medical units specialized in the care of CNTD (i.e. overweight, obesity, cardiovascular risk and diabetes), named UNEMES (from its Spanish initials). These units -consisting of an ad-hoc, trained, multi-disciplinary team- will provide patient education, help in the resolution of obstacles limiting treatment adherence, and involve the family in patient care. Treatment will be provided using standardized protocols. The efficacy of the intervention will be regularly measured using pre-specified outcomes. We expect that these UNEMES will result in significant savings. In summary, our health care system is developing better treatment strategies for CNTD. Evaluating the performance of the UNEMES will generate valuable information for the design of future preventive actions.

The Relationship between Depressive Symptoms in Outpatients with Chronic Illness and Health Care Costs

PURPOSE: To evaluate the relationship between depressive symptoms and health care costs in outpatients with chronic medical illnesses in Korea, we screened for depressive symptoms in 1,118 patients with a chronic medical illness and compared the severity of somatic symptoms and health care costs. PATIENTS AND METHODS: Data were compared between outpatients with depressive symptoms and those without depressive symptoms. Depression and somatic symptoms were measured by Zung's Self-rating Depression Scale (SDS) and Patient Health Questionnaire (PHQ)-15, respectively. We also investigated additional data related to patients' health care costs (number of visited clinical departments, number of visits made per patients, and health care costs). A total of 468 patients (41.9%) met the criteria for depressive disorder. RESULTS: A high rate of severe depressive symptoms was found in elderly, female and less-educated patients. A positive association between the severity of somatic symptoms and depressive symptoms was also identified. The effects of depressive symptoms in patients with chronic illnesses on three measures of health services were assessed by controlling for the effects of demographic variables and the severity of somatic symptoms. We found that the effects of depressive symptoms on the number of visited departments and number of visits made per patients were mediated by the severity of somatic symptoms. However, for health care costs, depressive symptoms had a significant main effect. Furthermore, the effect of gender on health care costs is moderated by the degree of a patient's depressive symptoms. CONCLUSION: In summary, there is clearly a need for increased recognition and treatment of depressive symptoms in outpatients with chronic medical illnesses.