[The annual cost of medical care for patients with moderate to severe atopic dermatitis in Mexico. A multicenter study]. / Costo anual de la atención médica de pacientes con dermatitis atópica moderada a grave en México. Estudio multicéntrico.

BACKGROUND: In Mexico, the economic burden of medical care for patients with atopic dermatitis is unknown. OBJECTIVE: To determine the annual direct medical costs of the treatment for patients with moderate to severe atopic dermatitis who receive medical attention at "Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado" (Institute for Social Security and Social Services for State Workers, better known as ISSSTE), as well as the main variables associated with it. METHODS: A multicenter, retrospective cohort study. Clinical records of patients with moderate to severe atopic dermatitis were reviewed and a multivariate analysis was designed by using a generalized linear model. RESULTS: 65 patients were included; 41 of them (63.07 %) had moderate atopic dermatitis, and 24 (36.92 %) had severe AD; 39 (60 %) of them were female patients. In groups with severe atopic dermatitis, statistically significant differences were observed in matters of the duration of the evolution of the disease, comorbidities, intense pruritus, and depression. The average annual cost of medical care for patients with moderate atopic dermatitis was 1527 ± 623 USD, and for patients with severe atopic dermatitis the cost was 9487 ± 8990 USD. Significant differences were observed in dermatology consultations, referrals, laboratory and diagnostic studies, and the number of drugs prescribed by physicians. With the multivariate analysis, it was identified that the highest cost was presented by severe patients (p = 0.0001) who were younger and had comorbidities, along with diagnosis of depression. CONCLUSIONS: The severity of atopic dermatitis, the age average, the presence of comorbidities, and the diagnosis of depression are the variables with the highest association and impact on the direct cost of medical care.

Antecedentes: En México se desconoce el impacto económico de la atención médica de los pacientes con dermatitis atópica. Objetivo: Determinar los costos médicos directos anuales del tratamiento de pacientes con dermatitis atópica moderada y grave que se atienden en el Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, y las principales variables asociadas. Métodos: Estudio multicéntrico de cohorte retrospectiva. Se revisaron los expedientes clínicos de pacientes con dermatitis atópica clasificada como moderada o grave y se diseñó un modelo de análisis multivariado mediante un modelo lineal generalizado. Resultados: Se incluyeron 65 pacientes, 41 (63.07 %) tuvieron dermatitis atópica moderada y 24 (36.92 %), grave; 39 (60 %) fueron del sexo femenino. En los grupos con dermatitis atópica grave se observaron diferencias estadísticamente significativas en años de evolución de la enfermedad, comorbilidades, prurito intenso y depresión. El costo promedio anual de la atención médica para dermatitis atópica moderada fue de 1527 ± 623 USD y para dermatitis atópica grave, de 9487± 8990 USD. Se obtuvieron diferencias estadísticamente significativas en consultas de dermatología, interconsultas, estudios de laboratorio y gabinete y número de medicamentos prescritos. Con el análisis multivariado se identificó que el costo mayor lo presentaban los pacientes graves (p = 0.0001), más jóvenes, con comorbilidades y diagnóstico de depresión. Conclusiones: La gravedad de la dermatitis atópica, la edad, presentar comorbilidades y contar con el diagnóstico de depresión son las variables con mayor asociación e impacto en el costo directo de la atención médica.

Costos medicos directos en pacientes con enfermedad pulmonar obstructiva Crónica en Mexico.

INTRODUCTION: chronic obstructive pulmonary disease (COPD) is a progressive, incurable and potentially mortal. COPD generates a high burden of illness and decreased quality of life in patients. The aim of this study was to determine the direct medical cost of COPD and the primary variables associated. METHODOLOGY: We conducted a multicenter clinical study, based in a retrospective cohort as base of a partial economic evaluation in patients diagnosed with moderate to severe COPD. It was considered an institutional point of view to determine medical costs, with an annual time horizon. For analysis of associations between explanatory and end point variables, a generalized lineal regression model was developed. RESULTS: We analyzed data from 283 patients, Fifty-nine percent were women, the average age was 72 years ± 11, Sixty-five percent of patients had a history of smoking and 57.6 % were exposed to wood smoke. The annual direct medical costs (MXN 2016) was 20,754 and 41,887 for patients with moderate and severe COPD, respectively, this difference is mainly due to the use of oxygen as well as longer hospital stay (12.9 vs. 24.7 days) of patients with severe COPD. CONCLUSIONS: Although the severity level is associated with greater health care costs, the quality of life of the patients should be considered carefully because it is inversely associated with the cost of care for patients with COPD.

La disminución de triyodotironina se asocia con la elevación del péptido natriurético cerebral N-terminal y con la mortalidad en pacientes en diálisis / Low triiodothyronine is associated with elevation of N-terminal pro-brain natriuretic peptide (NT-proBNP) and mortality in dialysis patients

Antecedentes: La disminución de hormonas tiroideas (HT) y el daño miocárdico son frecuentes en pacientes en diálisis y están asociados con la mortalidad. Sin embargo, poco se conoce de la importancia de las HT como factor de daño miocárdico, como se ha descrito en las enfermedades tiroideas primarias. El objetivo de este estudio fue explorar si existe interacción entre la disminución de triyodotironina total (tT3) y los marcadores de daño miocárdico y la relación de esta interacción entre ambos con la mortalidad, para establecer si el daño cardiovascular es el vínculo entre la disminución de HT y el riesgo de muerte en pacientes con ERC en diálisis. Material y métodos: Se estudiaron los niveles plasmáticos de HT, de marcadores de nutrición, inflamación y de daño al miocardio en 296 pacientes en diálisis peritoneal o en hemodiálisis, a los que se vigiló por 16 meses para conocer la asociación de las variables bioquímicas con la mortalidad. Resultados: En el 45% de los pacientes se encontró tT3 disminuida, lo cual tuvo correlación inversa con la proteína C reactiva (PCR) y con el NT-proBNP y directa con la albúmina y la transferrina. La diabetes, la PCR y la tT3 fueron factores de riesgo para la mortalidad por cualquier causa y la PCR, el NT-proBNP y la tT3 para mortalidad cardiovascular. Conclusiones: Los niveles bajos de tT3 son frecuentes en pacientes en diálisis, se asocian con inflamación, desnutrición y daño miocárdico: este último puede ser el vínculo entre la disminución de HT y la mortalidad por cualquier causa y la mortalidad cardiovascular (AU)

Background: Low thyroid hormone (TH) levels and myocardial damage are common in dialysis patients and are associated with mortality. However, little is known about the role of THs on myocardial damage as has been described in primary thyroid diseases. The aim of this study was to explore the potential relationship between low total triiodothyronine (total T3) and biomarkers of myocardial damage and the effect of their interaction on mortality, to ascertain if cardiovascular damage is the link between low THs and the risk of death in dialysis patients with CKD. Material and methods: TH plasma levels, nutritional markers, inflammation and myocardial damage were studied in 296 patients undergoing peritoneal dialysis or haemodialysis, who were followed up for 16 months to ascertain the association between biochemical variables and mortality. Results: Low total T3 levels were found in 45% of patients, which was inversely correlated with C-reactive protein (CRP) and NT-proBNP, and directly correlated with albumin and transferrin. Diabetes, CRP and total T3 were risk factors for all-cause mortality, and CRP, NT-proBNP and total T3 for cardiovascular mortality. Conclusions: Low total T3 levels are common in dialysis patients and are associated with inflammation, malnutrition and myocardial damage. The latter may be the link between low THs and all-cause and cardiovascular mortality (AU)

Low triiodothyronine is associated with elevation of N-terminal pro-brain natriuretic peptide (NT-proBNP) and mortality in dialysis patients. / La disminución de triyodotironina se asocia con la elevación del péptido natriurético cerebral N-terminal y con la mortalidad en pacientes en diálisis.

BACKGROUND: Low thyroid hormone (TH) levels and myocardial damage are common in dialysis patients and are associated with mortality. However, little is known about the role of THs on myocardial damage as has been described in primary thyroid diseases. The aim of this study was to explore the potential relationship between low total triiodothyronine (total T3) and biomarkers of myocardial damage and the effect of their interaction on mortality, to ascertain if cardiovascular damage is the link between low THs and the risk of death in dialysis patients with CKD. MATERIAL AND METHODS: TH plasma levels, nutritional markers, inflammation and myocardial damage were studied in 296 patients undergoing peritoneal dialysis or haemodialysis, who were followed up for 16 months to ascertain the association between biochemical variables and mortality. RESULTS: Low total T3 levels were found in 45% of patients, which was inversely correlated with C-reactive protein (CRP) and NT-proBNP, and directly correlated with albumin and transferrin. Diabetes, CRP and total T3 were risk factors for all-cause mortality, and CRP, NT-proBNP and total T3 for cardiovascular mortality. CONCLUSIONS: Low total T3 levels are common in dialysis patients and are associated with inflammation, malnutrition and myocardial damage. The latter may be the link between low THs and all-cause and cardiovascular mortality.

[Cost-effectiveness of anxiolytics in anxiety disorders]. / Costo-efectividad de ansiolíticos en los trastornos de ansiedad.

BACKGROUND: adequate treatment of anxiety disorders reduces the economic impact, improves functionality in daily life activities and quality of life. Pharmacologic treatment depends on patient's characteristics and doctor's experience. The aim of this study was to determine the use of resources in anxiety disorder and to analyze its cost-effectiveness. METHODS: use of resources related to chronic treatment of anxiety disorders and cost-effectiveness of drugs were determined, as well as patients' out-of-pocket expenses and productivity loss. A one-year time horizon and decision tree with benzodiazepines, selective inhibitor of serotonin re-intake (SISR) and tricyclic antidepressant drugs were included. RESULTS: benzodiazepines were the treatment that had the lowest total cost ($147,587 MXP), followed by SISR (incremental cost of $2,182 MXP), and the highest cost was tricyclic antidepressant drugs ($155,903 MXP). CONCLUSIONS: benzodiazepines are good alternative for anxiety disorder because of their high effectiveness to control symptoms and because they reduce hospital costs.

NT-proBNP, fluid volume overload and dialysis modality are independent predictors of mortality in ESRD patients.

BACKGROUND: N-terminal fragment of B-type natriuretic peptide (NT-proBNP) is a marker of both fluid volume overload and myocardial damage, and it has been useful as a predictor of mortality in patients with end-stage renal disease (ESRD). It has been suggested that continuous ambulatory peritoneal dialysis (CAPD), automated peritoneal dialysis (APD) and haemodialysis (HD) may have different effects on fluid volume and blood pressure control; however, whether the independent predictive value of NT-proBNP for mortality is preserved when analysed in conjunction with fluid overload and dialysis modality is not clear. METHODS: A prospective multicentre cohort of 753 prevalent adult patients on CAPD, APD and HD was followed up for 16 months. Plasmatic levels of NT-proBNP, extracellular fluid volume/total body water ratio (ECFv/TBW) and traditional clinical and biochemical markers for cardiovascular damage risk were measured, and their role as predictors of all-cause and cardiovascular mortality was analysed. RESULTS: NT-proBNP level, ECFv/TBW and other cardiovascular damage risk factors were not evenly distributed among the different dialysis modalities. NT-proBNP levels and ECFv/TBW were correlated with several inflammation, malnutrition and myocardial damage markers. Multivariate analysis showed that NT-proBNP levels and ECFv/TBW were predictors of both all-cause and cardiovascular mortality, independently of dialysis modality and the presence of other known clinical and biochemical risk factors. CONCLUSIONS: NT-proBNP is a reliable predictor of death risk independently of the effect of dialysis modality on fluid volume control, and the presence of other clinical and biochemical markers recognized as risk factors for all-cause and cardiovascular mortality. NT-pro-BNP is a good predictor of mortality independently of fluid volume overload and dialysis modality.

Effectiveness of two rehabilitation strategies provided by nurses for stroke patients in Mexico.

OBJECTIVE: Rehabilitation strategies have been developed to improve functional state in stroke patients. The main objective of this study was to evaluate the effectiveness of the early rehabilitation at hospital and its continuity at home provided by nurses, on the functional recovery of basic and social activities in stroke patients compared with conventional care. DESIGN: A randomised clinical trial was carried out in three general hospitals of the Mexican Institute of Social Security (IMSS) in Mexico City between April 2003-May 2004. PARTICIPANTS: Stroke patients. METHODS: Two rehabilitation strategies provided by nurses for stroke patients were compared: physiotherapy plus caregiver education in rehabilitation (strategy 1, S1) vs. education alone (strategy 2, S2). The main outcome variables were the basic (Barthel index) and social (Frenchay activities index) activities of daily living, of each patient. Age, sex, morbidity, stroke symptoms, complications, neurological damage (Canadian Scale), cognitive state (mini-mental state examination questionnaire) and duration of hospitalisation were defined as the control variables. Patients were evaluated at baseline and months one, three and six thereafter. RESULTS: One hundred and ten patients with ischaemic stroke were enrolled and randomised; 59 were assigned to S1 and 51 to S2. Comparison of the outcome variables showed that patients improved significantly over time, but no differences were observed between groups. We observed no significant difference in strategy performance with regard to the basic and instrumental activities of daily living. RELEVANCE TO CLINICAL PRACTICE: Participants who received physiotherapy with additional caregiver education benefit no more than those whose caregivers received education alone. Those countries that do not have integral rehabilitation programmes for stroke patients should understand their importance and budget resources for them. Meanwhile, both caregiver education and nurses trained in specific care and physiotherapy are alternatives that benefit these patients.

Gaining efficiencies: resources and demand for dialysis around the globe.

OBJECTIVES: End-stage renal disease (ESRD) is a debilitating condition resulting in death unless treated. Treatment options are transplantation and dialysis. Alternative dialysis modalities are peritoneal dialysis (PD) and hemodialysis (HD), each of which has been shown to produce similar outcomes and survival. Nevertheless, the financial implications of each modality are different and these differences vary by country, especially in the developing world. Changes in clinically appropriate dialysis delivery leading to more efficient use of resources would increase the resources available to treat ESRD or other disabling conditions. This article outlines the relative advantages of HD and PD and uses budget impact analysis to estimate the country-specific, 5-year financial implications on total dialysis costs assuming utilization shifts from HD to PD in two high-income (UK, Singapore), three upper-middle-income (Mexico, Chile, Romania), and three lower-middle-income (Thailand, China, Colombia) countries. RESULTS: Peritoneal dialysis is a clinically effective dialysis option that can be significantly cost-saving compared to HD, even in developing countries. CONCLUSIONS: The magnitude of costs associated with treating ESRD patients globally is large and growing. PD is a clinically effective dialysis option that can be used by a majority of ESRD patients and can also be significantly cost-saving compared to HD therapy. Increasing clinically appropriate PD use would substantially reduce health-care costs and help health-care systems meet ever-tightening budget constraints.

[Cost-effectiveness of the treatment of acute and chronic rhinosinusitis at the IMSS]. / Costo-efectividad del tratamiento de rinosinusitis aguda y crónica en el IMSS.

INTRODUCTION: Rhinosinusitis is one of the more common diseases encountered in outpatient visits to health care. The objective of this study was to determine the most cost-effective antibiotic treatment for patients with acute (RSA) and chronic rhinosinusitis (RSC) that is available at the Mexican Institute of Social Security (IMSS). METHODS: Cost-effectiveness analysis of RSA and RSC treatment from an institutional perspective. Effectiveness outcome was defined as the percentage of cure. A decision tree with a Bayesian approach included the following therapeutic alternatives: ciprofloxacin, gatifloxacin, trimetoprim/sulfametoxazol (TMP/SMX), amoxicilin/clavulanic acid (AAC) and clindamicin. RESULTS: Treatment for RSA with AAC showed a mean cost per cured patient of $ 878 pesos. The remaining antibiotics had a higher cost per unit of success, and therefore the results showed that AAC was the best alternative considering this criterion. The therapy that showed a larger percentage of cured patients in RSC was clindamicin; however, the therapeutic alternative with the lowest cost per successful unit was the one based on ciprofloxacin, which dominates gatifloxacin and AAC. CONCLUSIONS: The most cost-effective alternative in the antibiotic treatment of patients with RSA was ACC while for RSC it was ciprofloxacin; sensitivity analysis showed the strength of the base study results.

[Knowledge of medical doctors about health economics]. / Conocimientos de los médicos sobre economía de la salud.

OBJECTIVE: To identify the level of knowledge about health economics of physicians with different academic degree, working place and medical activities. MATERIAL AND METHODS: A questionnaire with 24 items about commonly used health economics concepts was applied. Face validity, content, construct, and consistency of the questionnaire were assessed. 523 Mexican physicians from public and private health institutions in Sinaloa and Distrito Federal were interviewed. RESULTS: The average general score was 4.1 +/- 2.1 (0 to 10 scale), for physicians at the IMSS was 4.1 +/- 2.1, SSA 4.3 +/- 2.5, ISSSTE 3.3 +/- 2; SEDENA 3.9 +/- 2.3 and in private medical services 4.4 +/- 2.2 (p = 0.001). Interns scored 3.7 +/- 2.1; physicians with specialties different from family medicine 4.3 +/- 2.2 and family physicians 4 +/- 2 (p = 0.05). The question that got the most correct answers was the definition of direct costs (82%) and the one with fewest was the percentage of the gross national product recommended by the World Health Organization for the health sector (11%). CONCLUSIONS: Interviewed physicians had poor knowledge about health economics. Academic degree and institutional work were factors related to that knowledge.

[Prescription of temporal disability certificates in workers attending to IMSS from the perspective of health economy]. / Prescripción de certificados de incapacidad temporal en el IMSS. Perspectiva desde la economía de la salud.

The repercussion of health-disease state on social life or individual includes his/her work performance. In many countries, social security is one of the options for diffusing and buffering the impact of the disease. This paper is focused on the analysis of the unjustified prescription of temporary sick leave certificates (CITT), which combines the social security medical components and economic benefits (subsidies). The objective is to analyze the mechanism of prescription of CITT from the perspective of health economics and health care services. The detailed flow of CITT at the Mexican Institute of Social Security is described, as are some concepts of the health economics perspective that contribute to explain the prescription of CITT. Statistical data of sick leaves due to work-related and non-work-related diseases are presented from the institutional perspective. Finally, it is emphasized that although CITT are a medical prescription, it is advisable to take into account the economic perspective and its concepts in order to achieve an efficient use of resources.

Cost-effectiveness of chronic hepatitis C treatment with thymosin alpha-1.

BACKGROUND: More than one million individuals in Mexico are infected with hepatitis C virus (HCV), and 80% are at risk for developing a chronic infection that could lead to hepatic cirrhosis and other complications that impact quality of life and institutional costs. The objective of the study was to determine the most cost-effective treatment against HCV among the following: peginterferon, peginterferon plus ribavirin, peginterferon plus ribavirin plus thymosin, and no treatment. METHODS: We carried out cost-effectiveness analysis using the institutional perspective, including a 45-year time frame and a 3% discount rate for costs and effectiveness. We employed a Bayesian-focused decision tree and a Markov model. One- and two-way sensitivity analyses were performed, as well as threshold-oriented and probabilistic analyses, and we obtained acceptability curves and net health benefits. RESULTS: Triple therapy (peginterferon plus ribavirin plus thymosin alpha-1) was dominant with lower cost and higher utility in relationship with peginterferon + ribavirin option, peginterferon alone and no-treatment option. In triple therapy the cost per unit of success was of 1,908 [USD/quality-adjusted life years (QALY)] compared with peginterferon plus ribavirin 2,277/QALY, peginterferon alone 2,929/QALY, and no treatment 4,204/QALY. Sensitivity analyses confirmed the robustness of the base case. CONCLUSIONS: Peginterferon plus ribavirin plus thymosin alpha-1 option was dominant (lowest cost and highest effectiveness). Using no drug was the most expensive and least effective option.

Direct medical costs for partial refractory epilepsy in Mexico.

BACKGROUND: The aim was to determine the direct medical costs in patients with partial refractory epilepsy at the Mexican Institute of Social Security (IMSS) in Mexico. METHODS: We carried out a multicenter, retrospective-cohort partial-economic evaluation study of partial refractory epilepsy (PRE) diagnosed patients and analyzed patient files from four secondary- and tertiary-level hospitals. PRE patients >12 years of age with two or more antiepileptic drugs and follow-up for at least 1 year were included. The perspective was institutional (IMSS). Only direct healthcare costs were considered, and the timeline was 1 year. Cost techniques were microcosting, average per-service cost, and per-day cost, all costs expressed in U.S. dollars (USD, 2004). RESULTS: We reviewed 813 files of PRE patients: 133 had a correct diagnosis, and only 72 met study inclusion criteria. Fifty eight percent were females, 64% were <35 years of age, 47% were students, in 73% maximum academic level achieved was high school, and 53% were single. Fifty one percent of cases experienced simple partial seizures and 94% had more than one monthly seizure. Annual healthcare cost of the 72 patients was 190,486 USD, ambulatory healthcare contributing 76% and hospital healthcare with 24%. CONCLUSIONS: Annual mean healthcare cost per PRE patient was 2,646 USD; time of disease evolution and severity of the patient's illness did not affect costs significantly.

Estudio de costo-efectividad de ceftriaxona y cefataxima en el tratamiento de neumonía adquirida en la comunidad / Cost-effectiveness study of ceftriaxone and cefotaxime for the treatment of community acquired pneumonia

Objetivo. Determinar la relación costo-efectividad de ceftriaxona y cefotaxima en el tratamiento de neumonía adquirida en la comunidad (NAC) de moderada a grave. Métodos. Se realizó un ensayo clínico en cinco hospitales del Instituto Mexicano del Seguro Social en el área metropolitana de la ciudad de México. Se comparó ceftriaxona con cefotaxima para el tratamiento de NAC, de moderada a grave, se evaluaron los costos de adquisición, preparación, aplicación, estancia hospitalaria y éxito terapéutico. Se calculó relación costo-efectividad, y se hicieron análisis de sensibilidad y análisis incremental. Resultados. Los principales gérmenes aislados fueron Streptococcus pneumoniae (23.6 por ciento) y Staphylococcus aureus (18.5 por ciento). La mayor parte de los microorganismos fueron sensibles a ceftriaxona, ceftazidima y cefotaxima, y resistentes a penicilina, ampicilina y eritromicina. El éxito terapéutico fue 98 por ciento en el grupo de ceftriaxona y 83 por ciento en el grupo de cefotaxima (p = 0.0091), la relación costo-efectividad por unidad porcentual de éxito fue $19,458.62 en el grupo de ceftriaxona y $29,218.08 en el grupo de cefotaxima. El análisis de sensibilidad mostró consistentemente menor relación costo-efectividad en el grupo de ceftriaxona. El análisis incremental basado en el tratamiento de 55 pacientes reveló que el uso de ceftriaxona en lugar de cefotaxima resulta en el ahorro de $35,170.79 por paciente adicional curado. Conclusiones. Ceftriaxona tiene menor relación costo-efectividad que cefotaxima en el tratamiento de NAC en pacientes con criterios de mal pronóstico que requieren hospitalización.

Los refrescos y la salud / Soft drinks and health

Objetivo. Analizar los artículos publicados sobre consumo de refrescos y describir los posibles beneficios, riesgos y daño a la salud relacionados con él. Fuente de información. Se realizó búsqueda y revisión en el sistema de discos compactos MEDLINE de enero de 1970 a enero de 1997 con las palabras soft drink, beverages, carbonated beverages, cola, Coca-Cola y sweetening-agents. Selección de estudios. Se revisaron 99 estudios en los que se describen daños o beneficios para la salud en estudios clínicos o experimentales. Extracción de los datos. Se consideraron todos los artículos en que se describió con claridad al menos un efecto benéfico o dañino relacionado con el consumo de refrescos. Resultados. Se identificarón 25 efectos dañinos y 7 efectos posiblemente benéficos. Los datos se clasifican en usos profilácticos y terapéuticos, caries dental y otros trastornos de los dientes, trastornos del metabolismo de los minerales, enfermedad ácido péptica, neoplasias, factores de riesgo para enfermedad cardiovascular, efectos sobre el sistema nervioso central, reproducción, alergia, contaminantes y misceláneos. Conclusiones. La alta prevalancia de exposición y el consumo excesivo de refrescos, pueden representar un problema de salud pública en México. El análisis de los datos muestra que el consumo de refresco puede no ser tan inocuo como generalmente se cree. Muchos de los informes son anecdóticos, sin diseño metodológico adecuado. Se identifica un campo de investigación amplio en esta área