Tuberculosis patients face high treatment support costs in Colombia, 2021.

OBJECTIVE: To estimate the baseline to measure one of the three indicators of the World Health Organization (WHO) End TB strategy (2015-2035), measure the costs incurred by patients affected by tuberculosis (TB) during a treatment episode and estimate the proportion of households facing catastrophic costs (CC) and associated risk factors, in Colombia, 2021. MATERIAL AND METHODS: A nationally representative cross-sectional survey was conducted among participants on TB treatment in Colombia, using telephone interviews due to the exceptional context of the COVID-19 pandemic. The survey collected household costs (direct [medical and non-medical out-of-pocket expenses] and indirect) over an episode of TB, loss of time, coping measures, self-reported income, and asset ownership. Total costs were expressed as a proportion of annual household income and analyzed for risk factors of CC (defined as costs above 20% annual household income). RESULTS: The proportion of TB-affected households incurring in costs above 20% annual household income (CC) was 51.7% (95%CI: 45.4-58.0) overall, 51.3% (95%CI: 44.9-57.7) among patients with drug-sensitive (DS) TB, and 65.0% (95%CI: 48.0-82.0) among drug-resistant (DR). The average patient cost of a TB case in Colombia was $1,218 (95%CI 1,106-1,330) including $860.9 (95%CI 776.1-945.7) for non-medical costs, $339 (95%CI 257-421) for the indirect costs, and $18.1 (95%CI 11.9-24.4) for the medical costs. The factors that influenced the probability of facing CC were income quintile, job loss, DR-TB patient, and TB type. CONCLUSION: Main cost drivers for CC were non-medical out-of-pocket expenses and income loss (indirect costs). Current social protection programs ought to be expanded to mitigate the proportion of TB-affected households facing CC in Colombia, especially those with lower income levels.

How Possible Is the Elimination of Viral Hepatitis? An Analysis Based on the Global Burden of Disease from Hepatitis B and C, 1990-2019.

This study assesses the feasibility of hepatitis B (HBV) and C (HCV) elimination using an analysis of trends of epidemiology data (1990-2019) from the Global Burden of Disease Study. Joinpoint regression analysis was used to identify significantly changing points in the trends of Age-standardized Prevalence Rates (ASPR) and Age-standardized Mortality Rates (ASMR) and to estimate the annual percentage changes (APC) and the average annual percentage changes (AAPC) for the period. The Sociodemographic Index (SDI) was used to analyze trends between countries. The total percentage change of the ASPR (2019/1990) was -31.4% and -12.8% for HBV and HCV worldwide, respectively; the rate ratio (HBV/HCV) was 2.5. Mortality had decreased for HBV but not for HCV. The total percentage change for the ASMR (2019/1990) was -26.7% and 10.0% for HBV and HCV, respectively. While the ASMR of HBV decreased, HCV increased during this period. The percentage change in ASMR of HBV was highest in countries with high-middle SDI and lowest in countries with high SDI. For HCV, the percentage change in ASMR was highest in countries with high SDI (increase), and only in countries with low SDI did it decrease. The global HBV and HCV rates have fallen with different AAPCs associated with the SDI. Despite the advances, there is still a long way to go to achieve the 2030 elimination goals. An important challenge is related to finding a way to speed up the yearly rate at which the decline is happening.

Effectiveness and safety of dupilumab in adults with moderate and severe atopic dermatitis in Colombia: Real-life experience.

Background: Dupilumab is a treatment approved for uncontrolled moderate-to-severe atopic dermatitis (AD). Tropical and developing countries such as Colombia have characteristics that may impact the natural history of AD and access to medical treatments. In that sense, we aimed to describe the effectiveness and safety of dupilumab in adults with moderate to severe AD in a Colombian multicenter cohort. Methods: Multicenter descriptive study that included patients who started treatment between March 2018 and May 2020 in 6 centers. Disease severity was assessed using the following: Scoring Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (EASI), Patient Oriented Eczema Measure (POEM), and Dermatology Life Quality Index (DLQI). These measurements were collected according to availability at baseline, 3-5 months, 6-12 months, and more than 12 months. Days of sick leave, hospitalizations, and AD flares before and after dupilumab treatment were reported. Adverse events (AEs) were recorded during follow-up. Results: Ninety-three patients were included, with a median age of 32 years (IQR: 24.0; 40.0) and a disease evolution time of 21 years (IQR: 16.0; 29.5). 88.2% had at least 1 allergic disease other than AD. An improvement greater than or equal to 75% EASI was observed in 41.7% of patients at 3-5 months, in 73.7% of patients at 6-12 months, and in 75.0% of patients after 12 months. For those reporting SCORAD and POEM, the median percent change ([IQR], n) from baseline in SCORAD was -67.1 ([-79.2; -54.2], n = 16), -70.5 ([-85.8; -47.9], n = 36) and -66.7 ([-77.3; -51.0], n = 13); and POEM, -58.6 ([-66.4; -55.5], n = 4), -73.0 ([-86.5; -66.7], n = 16) and -87.3 ([-93.4; -69.6], n = 8), respectively. Before initiation of dupilumab treatment, 82 (88.2%) patients reported at least 1 flare of AD in the past 12 months. During the follow-up period, 30 (32.3%) patients reported at least 1 exacerbation or flare. Twelve patients (12.9%) presented an AE and 3 (3.2%) patients discontinued dupilumab for this cause. Conclusions: Dupilumab was effective and safe for the treatment of moderate to severe AD in point-of-care settings, with results similar to randomized controlled and other real-life studies. These positive results are still maintained even though a high number of patients had short interruptions in the use of dupilumab due to administrative problems.

Burden of COVID-19 in Córdoba, A Department of Colombia: Results of Disability-Adjusted Life-Years: Carga de COVID-19 en Córdoba, un Departamento de Colombia: Resultados de los Años de Vida Ajustados por Discapacidad.

OBJECTIVES: This study aimed to estimate the burden of acute COVID-19 in Córdoba, one of the most affected departments (states) in Colombia, through the estimation of disability-adjusted life-years (DALYs). METHODS: DALYs were estimated based on the number of cases of severe acute respiratory syndrome coronavirus 2 infection cases reported by official Colombian sources. A transition probability matrix among severity states was calculated using data obtained from a retrospective cohort that included 1736 COVID-19 confirmed subjects living in Córdoba. RESULTS: Córdoba had 120.23 deaths per 100 000 habitants during the study period (March 2020 to April 2021). Estimated total DALYs were 49 243 (2692 DALYs per 100 000 inhabitants), mostly attributed to fatal cases (99.7%). On average, 25 years of life were lost because of death by this infection. A relevant proportion of years of life lost because of COVID-19 (46.6%) was attributable to people < 60 years old and was greater in men. People ≥ 60 years old showed greater risk of progression to critical state than people between the age of 35 and 60 years (hazard ratio 2.5; 95% confidence interval 2.5-12.5) and younger than 35 years (9.1; 95% confidence interval 4.0-20.6). CONCLUSION: In Córdoba, premature mortality because of COVID-19 was substantially represented by people < 60 years old and was greater in males. Our data may be representative of Latin American populations with great infection spread during the first year of the pandemic and contribute to novel methodological aspects and parameter estimations that may be useful to measure COVID-19 burden in other countries of the region.

Direct Medical Costs and Healthcare Resource Utilization of Treating Patients With Two Clinical Subtypes of Axial Spondyloarthritis in Colombia.

OBJECTIVES: This study aimed to calculate the healthcare resource utilization and direct medical costs in patients with 2 subtypes of axial spondyloarthritis (axSpA) in a rheumatic care center in Colombia. METHODS: This is a retrospective cost-of-illness study. Patients with at least 1 medical consultation associated with an axSpA diagnosis between October 2018 and October 2019 were identified. Patients were classified as having radiographic (r-axSpA) or nonradiographic axSpA (nr-axSpA). Direct medical costs were calculated in Colombian pesos and expressed in American dollars using an exchange rate of 3263 Colombian pesos = 1 US dollar ($). Predictors of total direct costs were identified using a generalized linear model with gamma distribution and log-link. RESULTS: A total of 162 patients with a mean age of 49.6 years (± 13.7) were included in the study. Among these, 147 (90.7%) were considered as having r-axSpA and 15 (9.3%) nr-axSpA, with mean costs of $6600 (± 6203) and $843 (± 1135), respectively (P < .001). The total direct mean cost was calculated at $6067 (± 6144) per patient. Medication costs were the main driver of total costs (97.6%, $5921), with biologic disease-modifying antirheumatic drugs accounting for nearly 92.0% ($5582) of these costs. Rheumatologist (100%) and physiatrist (64.2%) visits were the most frequently used medical service. CONCLUSIONS: The economic burden associated with axSpA in the Colombian setting is substantial. There is a significant difference in direct medical costs between the r-axSpA and the nr-axSpA. Health policies aimed at the comprehensive management of nr-axSpA would have an important role in the reduction of the associated direct medical costs.

Effectiveness of CoronaVac and BNT162b2 COVID-19 mass vaccination in Colombia: A population-based cohort study.

Background: In February 2021, Colombia began mass vaccination against COVID-19 using mainly BNT162b2 and CoronaVac vaccines. We aimed to estimate vaccine effectiveness (VE) to prevent COVID-19 symptomatic cases, hospitalization, critical care admission, and deaths in a cohort of 796,072 insured subjects older than 40 years in northern Colombia, a setting with a high SARS-CoV-2 transmission. Methods: We identified individuals vaccinated between March 1st of 2021 and August 15th of 2021. We included symptomatic cases, hospitalizations, critical care admissions, and deaths in patients with confirmed COVID-19 as main outcomes. We calculated VE for each outcome from the hazard ratio in Cox proportionally hazards regressions (adjusted by age, sex, place of residence, diabetes, human immunodeficiency virus, cancer, hypertension, tuberculosis, neurological diseases, and chronic renal disease), with 95% confidence intervals (CI). Findings: A total of 719,735 insured participants of 40 and more years were followed. We found 21,545 laboratory-confirmed symptomatic COVID-19 among unvaccinated population, along with 2874 hospitalizations, 1061 critical care admissions, and 1329 deaths, for a rate of 207.2 per million person-days, 27.1 per million person-days, 10.0 per million person-days, and 12.5 per million person-days, respectively. We found CoronaVac was not effective for any outcome in subjects above 80 years old; but for people 40-79 years of age, we found two doses of CoronaVac reduced hospitalization (33.1%; 95% CI, 14.5-47.7), critical care admission (47.2%; 95% CI, 18.5-65.8), and death (55.7%; 95% CI, 32.5-70.0). We found BNT162b2 was effective for all outcomes in the entire population of subjects above 40 years of age, significantly declining for subjects ≥80 years. Interpretation: Two doses of either CoronaVac in population between 40 and 79 years of age, or BNT162b2 among vaccinated above 40 years old significantly reduced deaths of confirmed COVID-19 in a cohort of individuals from Colombia. Vaccine effectiveness for CoronaVac and BNT162b2 declined with increasing age. Funding: UK National Institute for Health Research, the European Union's Horizon 2020 research and innovation programme, and the Bill & Melinda Gates Foundation.

How Expensive Are Hospitalizations by COVID-19? Evidence From Colombia.

OBJECTIVES: This study aimed to estimate the direct medical costs due to hospitalizations by COVID-19 in Colombia and to identify their cost drivers in Colombia. METHODS: This is a retrospective cost-of-illness study of COVID-19 in Colombia. We estimated direct medical costs using data from patients insured to a Benefit Plan Administrator Company, between March 15, 2020 and May 29, 2020. Absolute and relative frequencies, averages, medians, and interquartile ranges (IQRs) were used to characterize the population and estimate the costs of hospitalized patients with COVID-19. We stratified the cost analysis by sex, age groups, comorbidities, and type of hospitalization (general ward and intensive care unit [ICU]). Cost drivers were calculated from a generalized linear model. RESULTS: We studied 113 confirmed patients, 51.3% men. On average, the hospital length of stay was 7.3 (± 6.2) days. A person hospitalized with COVID-19 reported median costs of $1688 (IQR 788-2523). In women, this cost was $1328 (IQR 463-2098); in men, this was 1.4 times greater. The median cost for ICU was $4118 (IQR 2069-5455), 3 times higher than those hospitalized only in the general ward. Admission to the ICU, having 1 comorbidity, length of stay, high blood pressure, having 5 comorbidities, and being treated in the city of Cartagena were statistically significant with direct medical costs. CONCLUSIONS: Our study provides an idea of the magnitude of costs needed to hospitalize a COVID-19 case in Colombia. Other studies in Colombia have assessed the costs of hospitalization for infectious diseases such as influenza, costs significantly lower than those described here.

Substantial Out-of-Pocket Health Expenditure on Prenatal Check-Ups: Estimates from a Sample of Pregnant Women in Cartagena, Colombia.

OBJECTIVE: We aimed to estimate out-of-pocket (OOP) health expenditures and the indirect costs related to prenatal check-ups in pregnant women seen in a maternity hospital in the Colombian Caribbean region. METHODS: We described the economic costs of pregnant women, with no age limits, who attended prenatal check-ups in a maternity hospital. To estimate OOP and indirect costs owing to prenatal check-ups in pregnant women, a survey was constructed, where the woman was asked about some sociodemographic variables, to characterize those attending the prenatal check-ups. Absolute and relative frequencies, averages and confidence intervals were used to characterize the population and estimate OOP and indirect costs in pregnant women. The latter were estimated from the percentile method. A bootstrapping was performed to reduce the bias within the analysis. RESULTS: In total, 56 pregnant women were surveyed, with an average age of 25.9 years (±6.2). All women surveyed had OOP associated to the prenatal check-up in at least one cost-item, and the OOP ranged between $0.3 and $108.7. Transportation was the item with the highest frequency of expenses, followed by food, other expenses, and drugs. The mean of OOP expenditures was $24.3 (CI 95% $18.1-31.4) for women who attended their prenatal check-up. DISCUSSION: Considering the estimated OOP health expenditures caused by prenatal check-ups by household income, women living with <1 minimum wage spend 7% of their income in a prenatal check-up. In women with 1-2 and >2-3 minimum wages, these proportions were 5%, 3%, respectively. Unfortunately, this makes prenatal care a significant source of economic burden, impacting poor households in Cartagena.

Centers of Excellence Implementation for Treating Rheumatoid Arthritis in Colombia: A Cost-Analysis.

BACKGROUND: Health systems need to optimize the use of resources, especially in high-cost diseases as rheumatoid arthritis (RA). We aimed to evaluate the efficiency of using centers of excellence (CoE) as a strategy for improving RA treatment in Colombia. METHODS: A cost description analysis was carried out using the standard costing technique. We estimated the costs of medical consultations, laboratories, images, and medications for RA. Categories of care standards stratified by severity were defined using the disease activity score in 28 joints (DAS28). We evaluated the impact, in terms of costs (US dollars), for providing RA clinical care for a previously described cohort using the CoE approach. Statistical analyses were performed in Microsoft Excel®, and R. RESULTS: Expenditure on therapeutic drugs increases as the severity of RA increases. Drugs represent 53.6% of the total cost for the low disease activity (LDA) stage, 75.2% for moderate disease activity (MDA), 88.5% for severe disease activity (SDA) and 97% for SDA with biologic treatment (SDA+Biologic). Treating 968 patients would cost US$612,639 (US$487,978-1,220,160) at baseline, per year. After a year of follow-up at the CoE, treating the same patients would cost US$388,765 (US$321,710-708,476), which implies potential cost-savings of up to US$223,874 per year. CONCLUSION: The strategy of providing clinical care for RA through CoE can save US$231.3 per patient-per year. The results of our study show that CoE could greatly impact the public policies dealing with treatment of RA in Colombia. Applying the CoE model in our country would both improve health outcomes, as well as being more efficient in terms of costs.

Quantifying Potential Cost-Savings Through an Alternative Imaging-Based Diagnostic Process in Presumptive Seronegative Rheumatoid Arthritis.

BACKGROUND: Seronegative rheumatoid arthritis (SRA) is a condition that is not well understood and difficult to confirm by a conventional diagnostic process. We aimed to quantify the potential cost-savings of an alternative diagnostic process (ADP) imaging-based, for patients with presumptive SRA from everyday clinical practice. METHODS: We performed a retrospective analysis for patients with presumptive SRA who tested negative for both rheumatoid factor and anti-cyclic citrullinated peptide antibodies, through an ADP imaging-based, that is a standard clinical practice in our center. After we confirmed the diagnosis of SRA or reclassified patients in terms of another proper diagnosis, we estimate direct costs in two scenarios: a conventional and ADP. We compared the cost of RA treatment during the first year against the cost of the most misdiagnosed treatment (osteoarthritis) found after applying the ADP to determine potential cost-savings. RESULTS: We included 440 patients with a presumptive diagnosis of SRA. According to the imaging-based ADP, SRA was confirmed in 106/440 (24.1%), unspecified RA in 9/440 (2.0%), and osteoarthritis in 325/440 (73.9%) of those patients. Although the costs of conventional diagnosis per patient is lower than those of ADP ($59,20 USD vs $269,57 USD), we found a potential drug cost-savings of $1,570,775.20 US Dollars after 1 year of correct treatment. CONCLUSION: An alternative diagnosis process, including X-rays, US and MRI imaging, and clinical and blood-test assessment, not only increased diagnostic certainty in patients referred for evaluation of presumptive SRA but also suggested a potential cost-savings in pharmacological treatments avoided in misdiagnosed patients.

Frequency of Health Care Resource Utilization and Direct Medical Costs Associated with Psoriatic Arthritis in a Rheumatic Care Center in Colombia.

OBJECTIVE: To estimate the frequency of health care resource utilization and direct medical costs associated with Psoriatic Arthritis (PsA) in a rheumatic care center in Colombia. METHODS: A retrospective prevalence-based cost of illness study under the Colombian health care system perspective was conducted. We analyzed the frequency of health care resource utilization and estimated direct medical costs using anonymized medical records of adult patients (≥18 years) diagnosed with PsA at a rheumatology care center in Bogotá, Colombia. Patients were required to have at least one medical visit linked to a PsA diagnosis (ICD-10 L40.5) between October 2018 and October 2019 and a previous diagnose by the CASPAR criteria. Data on hospitalization episodes was not available. Direct medical costs were estimated in Colombian pesos (COP) and reported in US dollars (USD) using an exchange rate of 1USD = 3263.4 COP. A multivariate generalized linear model was used for identifying potential cost predictors. RESULTS: A sample of 83 patients was obtained. Of these, 54.2% were women and had a mean (SD) age of 58.7 (12) years at baseline. On average, they had 2.2 and 3.8 medical visits to the dermatologist and rheumatologist in the study period. The total direct medical cost was estimated at 410,985 US Dollars. Medical visits, therapies, laboratory and imaging represented 3.2% of total expenses and medications the remaining 96.8%. Patients receiving conventional DMARDs (cDMARDs) had an associated mean cost of 1020.1 USD (CI 701.4-1338.8) in a year. Among patients treated with cDMARDs and biological DMARDs (bDMARDs) the mean cost increase to 8113.9 USD (SD 5182.0-95% CI 6575.1-9652.8). CONCLUSION: A patient under biological therapy can increase their annual cost by 7.9 times the cost of a patient in conventional therapy. This provided updated knowledge on the direct medical costs, from the provision of a rheumatic care center service, to support epidemiologic or pharmacovigilance models.

Trends in diabetes mortality identified from death certificates in Colombia, 1979-2017.

OBJECTIVE: To describe the mortality trends of diabetes mellitus (DM) in Colombia, by sex and age group, from 1979 to 2017. METHODS: We carried out an ecological study using mortality data from the Colombian National Administrative Department of Statistics. Crude and age-standardized annual mortality rates per 100 000 people were estimated. Trends of standardized rates were described by sex and age groups. Joinpoint regression models were performed to study mortality trends. RESULTS: Throughout the whole period, the total number of DM recorded deaths in Colombia was 200 650, 58% (116 316) in women (p<0.05). The age-standardized mortality rates (ASMR) by sex increased from 13.2 to 26.6 deaths per 100 000 in women and from 10.1 to 22.7 in men from 1979 to 1999. We observed a decrease from 26.6 to 15.4 per 100 000 in women, and from 22.7 to 15.9 in men for the period 1999-2017. The joinpoint regression analysis showed that the average annual percentage change of the period did not vary in both sexes (men: -0.2%, 95% CI -1.0 to 1.4%; women: 0.7%, 95% CI -0.1 to 1.6%). CONCLUSIONS: The DM mortality showed a decreasing trend after 2000 in women and 2004 in men. Primary and secondary prevention programs must continue to be strengthened for an earlier diagnosis of diabetes.

OBJETIVO: Describir las tendencias de la mortalidad por diabetes mellitus (DM) en Colombia, por sexo y grupo de edad, entre 1979 y 2017. MÉTODOS: Estudio ecológico con datos de mortalidad del Departamento Administrativo Nacional de Estadística de Colombia. Se estimaron las tasas de mortalidad anuales brutas y ajustadas por edad por cada 100 000 personas. Se describieron las tendencias de las tasas ajustadas por sexo y grupos de edad. Se realizaron modelos de regresión joinpoint para estudiar las tendencias de la mortalidad. RESULTADOS: En el período del estudio, el número total de muertes por DM registradas en Colombia fue de 200 650, el 58% (116 316) en mujeres (p<0,05). Las tasas de mortalidad ajustadas por edad, en cada sexo, aumentaron de 13,2 a 26,6 muertes por 100 000 en las mujeres y de 10,1 a 22,7 en los hombres entre 1979 y 1999. En el período 1999-2017 se observó una disminución de 26,6 a 15,4 por 100 000 en las mujeres y de 22,7 a 15,9 en los hombres. El análisis de regresión joinpoint demostró que el cambio porcentual anual medio del período no varió en ambos sexos (hombres: ­0,2%, IC 95% ­1,0 a 1,4%; mujeres: 0,7%, IC 95% ­0,1 a 1,6%). CONCLUSIONES: La mortalidad por DM mostró una tendencia decreciente después del año 2000 en las mujeres y del 2004 en los hombres. Es necesario seguir fortaleciendo los programas de prevención primaria y secundaria a fin de alcanzar un diagnóstico más temprano de la diabetes.

Trends in diabetes mortality identified from death certificates in Colombia, 1979-2017

[ABSTRACT]. Objective. To describe the mortality trends of diabetes mellitus (DM) in Colombia, by sex and age group, from 1979 to 2017. Methods. We carried out an ecological study using mortality data from the Colombian National Administrative Department of Statistics. Crude and age-standardized annual mortality rates per 100 000 people were estimated. Trends of standardized rates were described by sex and age groups. Joinpoint regression models were performed to study mortality trends. Results. Throughout the whole period, the total number of DM recorded deaths in Colombia was 200 650, 58% (116 316) in women (p<0.05). The age-standardized mortality rates (ASMR) by sex increased from 13.2 to 26.6 deaths per 100 000 in women and from 10.1 to 22.7 in men from 1979 to 1999. We observed a decrease from 26.6 to 15.4 per 100 000 in women, and from 22.7 to 15.9 in men for the period 1999-2017. The joinpoint regression analysis showed that the average annual percentage change of the period did not vary in both sexes (men: -0.2%, 95% CI –1.0 to 1.4%; women: 0.7%, 95% CI –0.1 to 1.6%). Conclusions. The DM mortality showed a decreasing trend after 2000 in women and 2004 in men. Primary and secondary prevention programs must continue to be strengthened for an earlier diagnosis of diabetes.

[RESUMEN]. Objetivo. Describir las tendencias de la mortalidad por diabetes mellitus (DM) en Colombia, por sexo y grupo de edad, entre 1979 y 2017. Métodos. Estudio ecológico con datos de mortalidad del Departamento Administrativo Nacional de Estadística de Colombia. Se estimaron las tasas de mortalidad anuales brutas y ajustadas por edad por cada 100 000 personas. Se describieron las tendencias de las tasas ajustadas por sexo y grupos de edad. Se realizaron modelos de regresión joinpoint para estudiar las tendencias de la mortalidad. Resultados. En el período del estudio, el número total de muertes por DM registradas en Colombia fue de 200 650, el 58% (116 316) en mujeres (p<0,05). Las tasas de mortalidad ajustadas por edad, en cada sexo, aumentaron de 13,2 a 26,6 muertes por 100 000 en las mujeres y de 10,1 a 22,7 en los hombres entre 1979 y 1999. En el período 1999-2017 se observó una disminución de 26,6 a 15,4 por 100 000 en las mujeres y de 22,7 a 15,9 en los hombres. El análisis de regresión joinpoint demostró que el cambio porcentual anual medio del período no varió en ambos sexos (hombres: –0,2%, IC 95% –1,0 a 1,4%; mujeres: 0,7%, IC 95% –0,1 a 1,6%). Conclusiones. La mortalidad por DM mostró una tendencia decreciente después del año 2000 en las mujeres y del 2004 en los hombres. Es necesario seguir fortaleciendo los programas de prevención primaria y secundaria a fin de alcanzar un diagnóstico más temprano de la diabetes.

Trends in diabetes mortality identified from death certificates in Colombia, 1979-2017 / Tendencias de la mortalidad por diabetes identificadas a partir de los certificados de defunción en Colombia, 1979-2017

ABSTRACT Objective. To describe the mortality trends of diabetes mellitus (DM) in Colombia, by sex and age group, from 1979 to 2017. Methods. We carried out an ecological study using mortality data from the Colombian National Administrative Department of Statistics. Crude and age-standardized annual mortality rates per 100 000 people were estimated. Trends of standardized rates were described by sex and age groups. Joinpoint regression models were performed to study mortality trends. Results. Throughout the whole period, the total number of DM recorded deaths in Colombia was 200 650, 58% (116 316) in women (p<0.05). The age-standardized mortality rates (ASMR) by sex increased from 13.2 to 26.6 deaths per 100 000 in women and from 10.1 to 22.7 in men from 1979 to 1999. We observed a decrease from 26.6 to 15.4 per 100 000 in women, and from 22.7 to 15.9 in men for the period 1999-2017. The joinpoint regression analysis showed that the average annual percentage change of the period did not vary in both sexes (men: -0.2%, 95% CI -1.0 to 1.4%; women: 0.7%, 95% CI -0.1 to 1.6%). Conclusions. The DM mortality showed a decreasing trend after 2000 in women and 2004 in men. Primary and secondary prevention programs must continue to be strengthened for an earlier diagnosis of diabetes.

RESUMEN Objetivo. Describir las tendencias de la mortalidad por diabetes mellitus (DM) en Colombia, por sexo y grupo de edad, entre 1979 y 2017. Métodos. Estudio ecológico con datos de mortalidad del Departamento Administrativo Nacional de Estadística de Colombia. Se estimaron las tasas de mortalidad anuales brutas y ajustadas por edad por cada 100 000 personas. Se describieron las tendencias de las tasas ajustadas por sexo y grupos de edad. Se realizaron modelos de regresión joinpoint para estudiar las tendencias de la mortalidad. Resultados. En el período del estudio, el número total de muertes por DM registradas en Colombia fue de 200 650, el 58% (116 316) en mujeres (p<0,05). Las tasas de mortalidad ajustadas por edad, en cada sexo, aumentaron de 13,2 a 26,6 muertes por 100 000 en las mujeres y de 10,1 a 22,7 en los hombres entre 1979 y 1999. En el período 1999-2017 se observó una disminución de 26,6 a 15,4 por 100 000 en las mujeres y de 22,7 a 15,9 en los hombres. El análisis de regresión joinpoint demostró que el cambio porcentual anual medio del período no varió en ambos sexos (hombres: -0,2%, IC 95% -1,0 a 1,4%; mujeres: 0,7%, IC 95% -0,1 a 1,6%). Conclusiones. La mortalidad por DM mostró una tendencia decreciente después del año 2000 en las mujeres y del 2004 en los hombres. Es necesario seguir fortaleciendo los programas de prevención primaria y secundaria a fin de alcanzar un diagnóstico más temprano de la diabetes.

Education and pneumonia mortality: a trend analysis of its inequalities in Colombian adults.

OBJECTIVE: To explore the existence and trends of social inequalities related to pneumonia mortality in Colombian adults using educational level as a proxy of socioeconomic status. METHODS: We obtained individual and anonymised registries from death certificates due to pneumonia for 1998-2015. Educational level data were gathered from microdata of the Colombian Demography Health Surveys. Rate ratios (RR) were estimated by using Poisson regression models, comparing mortality of educational groups with mortality in the highest education group. Relative index of inequality (RII) was measured to assess changes in disparities, regressing mortality on the midpoint of the cumulative distribution of education, thereby considering the size of each educational group. RESULTS: For adults 25+ years, the risk of dying was significantly higher among lower educated. The RRs depict increased risks of dying comparing lower and highest education level, and this tendency was stronger in woman than in men (RR for primary education=2.34 (95% CI 2.32 to 2.36), RR for secondary education=1.77 (95% CI 1.75 to 1.78) versus RR for primary education=1.83 (95% CI 1.81 to 1.85), RR for secondary education=1.51 (95% CI 1.50 to 1.53)). According to age groups, young adults (25-44 years) showed the largest inequality in terms of educational level; RRs for pneumonia mortality regarding the tertiary educated groups show increased mortality in the lower and secondary educated, and these differences decreased with ages. RII in pneumonia mortality among adult men was 2.01 (95% CI 2.00 to 2.03) and in women 2.46 (95% CI 2.43 to 2.48). The RII was greatest at young ages, for both sexes. Time trends showed steadily significant increases for RII in both men and women (estimated annual percentage change (EAPC)men=3.8; EAPCwomen=2.6). CONCLUSION: A significant increase on the educational inequalities in mortality due to pneumonia during all period was found among men and women. Efforts to reduce pneumonia mortality in adults improving population health by raising education levels should be strengthened with policies that assure widespread access to economic and social opportunities.

Is Colombia an example of successful containment of the 2020 COVID-19 pandemic? A critical analysis of the epidemiological data, March to July 2020.

BACKGROUND: Colombia detected its first coronavirus disease 2019 (COVID-19) case on March 2, 2020. From March 22 to April 25, it implemented a national lockdown that, apparently, allowed the country to keep a low incidence and mortality rate up to mid-May. Forced by the economic losses, the government then opened many commercial activities, which was followed by an increase in cases and deaths. This paper presents a critical analysis of the Colombian surveillance data in order to identify strengths and pitfalls of the control measures. METHODS: A descriptive analysis of PCR-confirmed cases between March and July 25 was performed. Data were described according to the level of measurement. Incidence and mortality rates of COVID-19 were estimated by age, sex, and geographical area. Sampling rates for suspected cases were estimated by geographical area, and the potential for case underestimation was assessed using sampling differences. RESULTS: By July 25, Colombia (population 50 372 424) had reported 240 745 cases and 8269 deaths (case fatality rate of 3.4%). A total of 1 370 271 samples had been analyzed (27 405 samples per million people), with a positivity rate of 17%. Sampling rates per million varied by region from 2664 to 158 681 per million, and consequently the incidence and mortality rates also varied. Due to geographical variations in surveillance capacity, Colombia may have overlooked up to 82% of the actual cases. CONCLUSION: Colombia has a lower case and mortality incidence compared to other South American countries. This may be an effect of the lockdown, but may also be attributed, to some extent, to geographical differences in surveillance capacity. Indigenous populations with little health infrastructure have been hit the hardest.

Economic Cost of Severe Acute Respiratory Infection Associated to Influenza in Colombian Children: A Single Setting Analysis.

BACKGROUND: Influenza is considered a leading public health problem because its large economic burden of disease worldwide, especially in low-and middle-income countries, such as Colombia. OBJECTIVE: We aimed to estimate the economic costs of influenza-confirmed patients in a pediatric hospital in Cartagena, Colombia. METHODS: We conducted a retrospective costing analysis. We estimated the direct (direct medical and out-of-pocket expenditures) and indirect costs for influenza-confirmed severe acute respiratory infection cases from a societal perspective. Total economic costs were calculated adding direct medical costs, out-of-pocket expenditures, and indirect costs owing to loss of productivity of caregivers. Mean, median, 95% confidence interval (95% CI) and interquartile range (IQR) of costs were measured. All costs are reported in USD ($1.00 = COP$2000.7) RESULTS: Forty-four cases were included in the analysis: 30 had influenza B, 10 influenza A and B, and 4 influenza AH1N1. Thirty patients were hospitalized in the general ward, 14 went to the intensive care unit. The average duration of stay was ∼9 days (95% CI, 6.3-11.5). The median direct medical cost for hospitalized case in general ward was $743.50 (IQR $590.20-$1404.60) and in intensive care unit $4669.80 (IQR $1614.60-$7801.50). The economic cost per hospitalized case was $1826.10 (IQR $1343.30-$2376.50); direct medical costs represented 93.8% of this cost. The median indirect cost was $82.10 (IQR $41.10-$133.40) and the median out-of-pocket expenditure per case was $45.70 (IQR $29.50-$64.90). CONCLUSIONS: Severe acute respiratory infection is an important source of economic burden for the health system, families, and society in Colombia. Seasonal influenza vaccination should be strengthened to prevent more cases and save economic resources.

Carga económica de la enfermedad renal crónica en Colombia, 2015-2016 / Economic burden of Chonic Kidney Disease in Colombia, 2015-2016

RESUMEN Objetivo: Estimar la carga económica asociada a la enfermedad renal crónica (ERC) en Colombia, para el periodo 2015-2016. Materiales y métodos: Se estimó la carga económica de la ERC en Colombia a partir de datos de terceros pagadores. Se realizó un costeo de los estadios de la ERC mediante la técnica de macro-costeo o top-down, con el fin de conocer el impacto económico de cada estadio en la carga global de la enfermedad. Se construyó un modelo de Markov que simulara la historia natural de la enfermedad. Se utilizó una tasa de descuento del 5% y ciclos anuales. A cada estado de la ERC se le asignó un costo relacionado con la atención, con lo cual se obtuvo un estimado del costo y de la carga de enfermedad de todos los pacientes con ERC. Resultados: Al final de los ciclos de todos los pacientes desde el estadio 1-5, incluyendo el trasplante, se estimó una carga económica que asciende a COP 10,5 billones (IC 95% COP 8,7- COP 14,4). En el escenario con tasa de descuento del 5%, la carga económica asciende a COP 7,8 billones. Conclusión: La ERC representa una alta carga económica al sistema de salud colombiano, la cual oscila entre COP 8,7 y COP 14,4 billones, que representarían entre el 1,6% y el 2,7% del producto interno bruto de Colombia en el 2015.

ABSTRACT: Objective: Estimate the economic burden due to chronic kidney disease (CKD) in Colombia, for 2015-2016. Methods: We estimated the economic burden of CKD through third payer's data. A top-down technique was used to estimate the costs related to CKD as input to estimate the economic burden of the disease. A Markov model was conducted to simulate the natural history of the disease. A 5% discount rate and annual cycles were used. Each stage of the disease had a cost associated with the disease, producing and estimation of the economic burden of all patients with CKD. Results: At the end of the modeling from stages 1-5, including transplantation, the economic burden of CKD was COP $10.5 billion (IC 95% $8.7-$14.4). In the discount rate scenario, the economic burden was COP $7.8 billons. Conclusion: CKD represents a high economic burden on the Colombian health system, which ranges from COP $ 8.7- $ 14.4 billion that would represent between 1.6% and 2.7% of Colombia's Gross Domestic Product, 2015.

Costs of acute otitis media in children in a city of the Colombian Caribbean coast / Costos de la otitis media aguda en niños de una ciudad de la costa caribe colombiana

Abstract Introduction: Acute otitis media is the main cause of consultation, antibiotic use, and ambulatory surgery in developed countries; besides, it is associated with an important economic burden. However, non-medical indirect costs of acute otitis media, which are relevant in this pathology, have been underestimated. Objective: To estimate the costs of acute otitis media in pediatric patients in Cartagena, Colombia. Materials and methods: We conducted a prospective study of micro-costing between 2014 and 2015. The direct and indirect costs of acute otitis media were determined through forms applied to parents or caregivers. Loss of productivity was estimated based on the monthly legal minimum wage of 2014 (COP $616.000) (USD $308). Results: A total of 62 episodes of acute otitis media occurred. The total economic costs attributed per episode was COP $358,954 (standard deviation: SD ± COP $254,903, i.e., USD $179). The total economic burden was COP $22,503,141 (USD $11,250), the indirect costs per episode were COP $101,402 (USD $51), and the average care time spent by parents was 3.7 days. Conclusion: The estimated costs of acute otitis media in this study were lower than the costs estimated in a review of high-income countries and similar to those of low-income countries such as Nigeria. Information on total costs (direct and indirect) of acute otitis media is necessary for public health decision-making and for full cost-effectiveness assessments.

Resumen Introducción. La otitis media aguda es la principal causa de consultas médicas, de uso de antibióticos y de cirugías ambulatorias en los países desarrollados. Está asociada con una significativa carga económica, pero sus costos indirectos no médicos, los cuales son relevantes en esta enfermedad, se han subestimado. Objetivo. Estimar los costos de la otitis media aguda en pacientes pediátricos en Cartagena, Colombia. Materiales y métodos: Se hizo un estudio prospectivo de microcosteo entre el 2014 y el 2015. Se determinaron los costos directos e indirectos de la otitis media aguda mediante encuestas a los padres o cuidadores. La pérdida de productividad se estimó con base en el salario mínimo legal vigente mensual del 2014(COP$616.000) (USD$308). Resultados. Se presentaron 62 episodios de otitis media aguda. Los costos económicos totales por episodio fueron de COP $358.954 (desviación estándar, DE: ± $254.903) (USD $179). La carga económica total fue de COP $22'503.141 (USD $11.250), los costos indirectos por episodio fueron de COP $101.402 (USD $51) y el tiempo promedio empleado por los padres en el cuidado fue de 3,7 días. Conclusiones. Los costos estimados de la otitis media aguda en el presente estudio fueron menores a los estimados en países con ingresos altos y similares a los de países con ingresos bajos como Nigeria, según una revisión bibliográfica. La información sobre los costos totales directos e indirectos de la otitis es necesaria para la adopción de decisiones en salud pública y para hacer evaluaciones económicas completas de costo-efectividad.

Gasto de bolsillo y gasto catastrófico en salud en los hogares de Cartagena, Colombia / Out-of-pocket and catastrophic health expenditure in households of Cartagena, Colombia

RESUMEN Objetivo Estimar el gasto de bolsillo y la probabilidad de gasto catastrófico de los hogares y sus determinantes socioeconómicos en Cartagena, Colombia. Materiales y Métodos Estudio transversal en una muestra poblacional estratificada aleatoria de hogares de Cartagena. Se estimaron dos modelos de regresión cuyas variables dependientes fueron gasto de bolsillo y probabilidad de gasto catastrófico en salud de los hogares. Resultados El gasto de bolsillo promedio anual en hogares pobres fue 1 566 036 COP (US$783) (IC95% 1 117 597-2 014 475); en hogares de estrato medio 2 492 928 COP (US$1246) (IC95% 1 695 845-3 290 011) y en hogares ricos 4 577 172 COP (US$2 288) (IC95% 1 838 222-7 316 122). Como proporción del ingreso, el gasto de bolsillo en salud fue de 14,6% en los hogares pobres, de 8,2% en los hogares de estrato medio y de 7,0% en los hogares ricos. La probabilidad de gasto catastrófico en salud de los hogares pobres fue 30,6% (IC95% 25,6-35,5%), de los de estrato medio del 10,2% (IC95% 4,5-15,9%) y de los hogares de estrato alto del 8,6% (IC95% 1,823,0%). El estrato socioeconómico, la educación y la ocupación fueron los principales determinantes del gasto de bolsillo en salud y de la probabilidad de incurrir en gasto catastrófico en salud. Conclusiones En el sistema de salud persisten desigualdades en la protección financiera de los hogares contra el gasto de bolsillo y la probabilidad de gasto catastrófico. El presente estudio genera evidencia para revisar la política de protección social de los hogares socioeconómicamente más vulnerables.(AU)

ABSTRACT Objective To estimate out-of-pocket (OOP) health expenditure and the probability to incur in catastrophic health expenditure, as well as the socio-demographic determinants of households in Cartagena, Colombia. Materials and Methods Population-based cross-sectional study on a randomized stratified sample of Cartagena households. Two regression models were developed using OOP health expenditure and the probability to incur in catastrophic health expenditure as dependent variables. Results The average annual OOP health expenditure was $1 566 036 COP (US$783) (95%CI: $1 117 597 - $2 014 475) in poor households, $2 492 928 COP (US$1 246) (95%CI: $1 695 845 - $3 290 011) in middle class households, and $4 577 172 COP (uS$2 288) (95%CI: $1 838 222 - $7 316 122) in upper class households. Regarding the household income ratio, the OOP health expenditure was 14.6% in poor households, 8.2% in middle class, and 7.0% in upper class households. The probability to incur in catastrophic health expenditure was 30.6% (95%CI: 25.6% - 35.5%), 10.2% (95%CI: 4.5%-15.9%) and 8.6% (95%CI: 1.8%-23%) in the low, middle- and high-class households, respectively. Educational attainment, socioeconomic strata and employment were the main determinants of OOP and the probability to incur in catastrophic health expenditure. Conclusions The health system has persistent inequalities regarding the financial protection of households related to out-of-pocket expenditure and the probability of catastrophic expenditure. This study provides evidence to review the social protection policy for the most socio-economically vulnerable households.(AU)