Cost of cardiac care in the three years after coronary catheterization in a contained care system: critical determinants and implications.

OBJECTIVES: We sought to determine the clinical, angiographic, treatment and outcome correlates of the intermediate-term cost of caring for patients with suspected coronary artery disease (CAD). BACKGROUND: To adequately predict medical costs and to compare different treatment and cost reduction strategies, the determinants of cost must be understood. However, little is known about the correlates of costs of treatment of CAD in heterogeneous patient populations that typify clinical practice. METHODS: From a consecutive series of 781 patients undergoing cardiac catheterization in 1992 to 1994, we analyzed 44 variables as potential correlates of total (direct and indirect) in-hospital, 12- and 36-month cardiac costs. RESULTS: Mean (+/-SD) patient age was 65+/-10 years; 71% were men, and 45% had multiple vessel disease. The initial treatment strategy was medical therapy alone in 47% of patients, percutaneous intervention (PI) in 30% and coronary artery bypass graft surgery (CABG) in 24%. The 36-month survival and event-free (death, infarction, CABG, PI) survival rates were 89.6+/-0.2% and 68.4+/-0.4%, respectively. Median hospital and 36-month costs were $8,301 and $28,054, respectively, but the interquartile ranges for both were wide and skewed. Models for log(e) costs were superior to those for actual costs. The variances accounted for by the all-inclusive models of in-hospital, 12- and 36-month costs were 57%, 60% and 71%, respectively. Baseline cardiac variables accounted for 38% of the explained in-hospital costs, whereas in-hospital treatment and complication variables accounted for 53% of the actual costs. Noncardiac variables accounted for only 9% of the explained costs. Over time, complications (e.g., late hospital admission, PI, CABG) and drug use to prevent complications of heart transplantation became more important, but many baseline cardiac variables retained their importance. CONCLUSIONS: 1) Variables readily available from a comprehensive cardiovascular database explained 57% to 71% of cardiac costs from a hospital perspective over 3 years of care; 2) the initial revascularization strategy was a key determinant of in-hospital costs, but over 3 years, the initial treatment become somewhat less important, and late complications became more important determinants of costs.

The Brazilian Xavante Indians revisited: new protein genetic studies.

A total of 94 individuals from the Xavante village of Rio das Mortes were variously studied in relation to 28 protein genetic systems. No variation was observed for 15 of them, in accordance with previous studies. Of the remaining 13, four (Rh, Duffy, acid phosphatase, and GC) showed significant departures from the averages obtained in 32 other South American Indian populations. If studies performed in the 1960s are considered, there is indication that no significant changes in this village's gene pool has occurred in the last 30 years. Comparison with two other Xavante populations included nine systems with variation, and for three of them (MNSs, Rh, and Duffy) significant differences were found. Genetically the Rio das Mortes are closer to the São Marcos than to the Simões Lopes Xavantes. A dendrogram considering 25 genetic systems and 33 South American Indian populations was constructed. There the Xavante were grouped together, in two neighboring clusters, with three other tribes who speak Ge languages, But these clusters also present populations who speak other languages, and the reproducibility of the tree is low. South American Indians, at least with this set of markers, do not seem to be clearly classified into defined subgroups.

Hepatitis B epidemiology and cultural practices in Amerindian populations of Amazonia: the Tupí-Mondé and the Xavánte from Brazil.

Hepatitis B infection and disease are highly endemic in South America. Prevalences of positivity are particularly high in Amazonia, and among Amerindian peoples in particular. This paper reports the results of a seroepidemiological survey for hepatitis B virus (HBV) carried out among four Amerindian populations from the Brazilian Amazon region: Gavião, Surui, Zoro and Navate. Rates of positivity to HBV serological markers (HBsAg, anti-HBs and or anti-HBc) are very high for the four groups, ranging from 62.8 to 95.7%. It is argued that the high rates of positivity in the Amerindian groups dealt with in this study, as well as for other Amazonian populations, are related to a complex of cultural practices which enhance the likelihood of HBV transmission (bloodletting, scarification, tattooing and orally processed food, among others). The authors suggest that, due to unique patterns of interaction between sociocultural and environmental factors. HBV infection assumes a specific profile in native Amazonian societies.

Endemic pemphigus foliaceus (fogo selvagem) in native Americans from Brazil.

BACKGROUND: Fogo selvagem (FS) is an autoimmune disease that is endemic in certain regions of Brazil and appears to be precipitated by an environmental factor. OBJECTIVE: Our purpose was to confirm the occurrence and prevalence of FS in a population of Xavante Indians living in an endemic region of central Brazil. METHODS: Clinical, anthropologic, and immunologic studies were carried out in patients and in normal inhabitants of the Pimentel Barbosa Indian Reservation, Mato Grosso, Brazil. RESULTS: FS was identified and confirmed in 10 patients from a patient pool of 295 with various skin diseases. The Xavante settlement has a total population of 746. Anti-desmoglein 1 autoantibodies were detected in all patients with FS and were absent from more than 300 serum samples collected from randomly selected unaffected persons. CONCLUSION: FS is strongly linked to outdoor activities and is largely restricted to immunogenetically predisposed persons. FS appears to have been endemic in certain regions of South America for several centuries.

Intestinal parasitism in the Xavánte Indians, central Brazil.

This paper reports the findings of a survey for intestinal parasites among the Xavánte Indians from Central Brazil. A. lumbricoides (25.0%) and hookworms (33.6%) were the two most common helminths; E. histolytica complex (7.8%) and G. lamblia (8.6%) the most common protozoans. The majority (58.5%) of positive individuals hosted only one species of helminth. Egg counts for helminths, and for A. lumbricoides in particular, were found to be not dispersed at random, with a few individuals, all of whom young children, showing very high counts. The prevalence rates of intestinal parasites for the Xavánte are below those reported for other Amerindian populations from Brazil.

Ecology and acculturation among native peoples of central Brazil.

Simple exposure to Western goods may not be a sufficient explanation of why isolated village communities increase their participation in external market economies. The degree of market participation by four native villages in central Brazil is related to the difficulty of making a living from slash-and-burn subsistence agriculture as measured by the ratio of labor input to food output.