Desinvestimento de tecnologias em saúde no Sistema Único de Saúde: um perfil no período 2012-2022 / Disinvestment of health technologies in the Brazilian Unified Health System: a profile between 2012-2022

O termo "desinvestimento" se refere ao processo de retirada de recursos de intervenções que oferecem pouco ou nenhum ganho em saúde frente a seu custo. O intuito deste processo é reforçar práticas comprovadamente seguras, efetivas ou mais custo-efetivas, otimizando os resultados em saúde e a sustentabilidade econômica dos sistemas de saúde. O objetivo do trabalho foi caracterizar o processo de desinvestimento de medicamentos conduzido pela Comissão Nacional de Incorporação de Tecnologias (CONITEC) no Sistema Único de Saúde (SUS) entre 2012 e 2022, de forma exploratória através de análise documental dos seus relatórios técnicos de recomendações. Foram coletados nome do medicamento; sua classificação pelo sistema ATC; indicação clínica; demandante; realização de Consulta Pública; modalidade de desinvestimento recomendada e justificativa para o desinvestimento. Também foi avaliado o alinhamento das diretrizes de tratamento com as decisões de desinvestimento e o status de registro sanitário das tecnologias desinvestidas em diferentes ocasiões. Foram avaliados 30 relatórios de recomendação, correspondentes a 90 medicamentos. Três relatórios tiveram como recomendação a manutenção de sete tecnologias de perfil diversificado no SUS. Outros três relatórios eram referentes a tecnologias que foram incorporadas sob a modalidade ad experimentum e que, portanto, foram reavaliadas após três anos no SUS. Quanto às tecnologias efetivamente desinvestidas (80), elas se dividiram principalmente pelos grupos L (agentes antineoplásicos e imunomoduladores; 29,3%), J (anti-infecciosos de uso sistêmico; 21,3%) e A (aparelho digestivo e metabolismo; 20%). As principais indicações clínicas dos medicamentos desinvestidos foram: artrite reumatoide; HIV; hepatite C; e doença de Crohn. Justificativas mais mencionadas foram a indisponibilidade de registro ativo do medicamento no país (24,1%), seguida por problemas relacionados à segurança (20,6%) e efetividade (19,9%). Todas as demandas tiveram origem interna do Ministério da Saúde. Em 31,3%, houve exclusão do medicamento para indicação específica e, em 30%, exclusão total do sistema de saúde; em 27,5%, optou-se por excluir apenas determinada apresentação farmacêutica; em 10% as exclusões foram de apresentação para indicação específica; e em 1,2% ocorreu restrição de uso. Consulta Pública foi realizada em 36% dos casos. Após a publicação da Diretriz de Avaliação de Desempenho de Tecnologias em Saúde no final de 2016, o perfil de medicamentos desinvestidos por categoria ATC e por indicações clínicas adquiriram maior diversidade; as justificativas para o desinvestimento, que antes focavam em questões relacionadas a efetividade e segurança, passaram a se concentrar na indisponibilidade do medicamento no mercado; as modalidades de desinvestimento se acumularam mais em exclusões do SUS e exclusões de apresentação, e a Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos se tornou a principal demandante; submissão a consultas públicas subiu de 11,9% para 86,8%. O máximo de adequação estrutural identificado nos relatórios em relação aos tópicos preconizados pela Diretriz foi de 46,2%. Embora as iniciativas de desinvestimento tenham avançado nos últimos anos, o tema ainda enfrenta dificuldades para estabelecer uma agenda sólida no país.

Disinvestment refers to withdrawing resources from interventions that offer little or no health gain compared to their cost, seeking to reinforce practices proven to be safe, effective or more cost-effective and to optimize health outcomes and the economic sustainability of health systems. This study aimed to characterize the drug divestment process conducted by the National Commission for Incorporation of Technologies (CONITEC) in the Brazilian Unified Health System (SUS) between 2012 and 2022, in an exploratory way through their the technical recommendations reports. Drug name and ATC classification, clinical indication, proponents, occurrence of Public Consultation, recommended divestment modality and justifications for disinvestment were evaluated. We also evaluated the agreement of treatment guidelines with disinvestment decisions and the sanitary registration status of technologies disinvested at different times. We evaluated 30 recommendations reports corresponding to 90 drugs. Three reports recommended the maintenance of seven technologies in SUS. Another three reports referred to technologies that were incorporated under the ad experimentum modality and then were reassessed after three years in SUS. As for the technologies effectively disinvested (80), the drugs mainly belonged to the ATC classes L (29.3%), J (21.3%) and A (20%). The main clinical indications of the disinvested drugs were: rheumatoid arthritis, HIV, hepatitis C, and Crohn's disease. The main justifications were absence of market approval for the drug in Brazil (24.1%) and problems related to safety (20.6%) and effectiveness (19.9%). All requests were from the Brazilian Ministry of Health. Public Consultation was carried out in 36% of the situations. There were recommendations to exclude the drug for a specific indication in 31.3% of the cases and total exclusion from the SUS in 30%; exclusion of a particular pharmaceutical presentation and exclusion of presentation for a specific indication occurred in 27.5% and 10%, respectively. After the publication of the Methodological Guideline for Performance Avaliation of Health Technologies ate the end of 2016, the profile of drugs disinvested by ATC category and by clinical indications acquired bigger diversity; the justifications for disinvestment, which previously focused on issues related to effectiveness and safety, passed to focus on the unavailability of the drug on the market; disinvestment modalities concentrated more on SUS exclusions and presentation exclusions; the Secretaria of Science, Technology, Innovation and Strategic Insums became the main proponent of disinvestment demands; submission to public consultations grow up from 11.9% to 86.8%. The maximum structural adequacy identified of the reports in relation to the topics recommended by the Guideline was 46,2%. The lack of standardization and overly simplified reporting formats stood out. Although divestment initiatives have advanced in recent years, this theme still needs to improve in establishing a solid agenda in Brazil.

Use of discrete event simulation and genetic algorithms to estimate the necessary resources to respond in a timely manner in the Medical Emergency System in Bogotá. / Uso de simulación de eventos discretos y algoritmos genéticos para estimar los recursos necesarios para responder oportunamente en el sistema de emergencias médicas en Bogotá.

Introduction: Bogotá has a Medical Emergency System of public and private ambulances that respond to health incidents. However, its sufficiency in quantity, type and location of the resources demanded is not known. Objective: Based on the data from the Medical Emergency System of Bogotá, Colombia, we first sought to characterize the prehospital re- sponse in cardiac arrest and determine with the model which is the least number of resources necessary to respond within eight minutes, taking into account their location, number, and type. Methods: A database of incidents reported in administrative records of the district health authority of Bogotá (2014 to 2017) was obtained. Based on this information, a hybrid model based on discrete event simulation and genetic algorithms was designed to establish the amount, type and geographic location of resources according to the frequencies and typology of the events. Results: From the database, Bogotá presented 938 671 ambulances dispatches in the period. 47.4% high priority, 18.9% medium and 33.74% low. 92% of these corresponded to 15 of 43 medical emergency codes. The response times recorded were longer than expected, especially in out-of-hospital cardiac arrest (median 19 minutes). In the proposed model, the best scenario required at least 281 ambulances, medicalized and basic in a 3:1 ratio, respectively, to respond in adequate time. Conclusions: Results suggest the need for an increase in the resources that respond to these incidents to bring these response times to the needs of our population.

Introducción: Bogotá cuenta con un sistema de emergencias médicas de ambulancias públicas y privadas que responden a incidentes de salud. No se conoce, sin embargo, su suficiencia en cantidad, tipo y ubicación de recursos demandados. Objetivos: A partir de los datos del sistema de emergencias médicas de Bogotá, Colombia, se buscó primero caracterizar la respuesta pre hospitalaria en paro cardiaco. Luego, con el modelo se buscó determinar cuál sería el menor número de recursos necesarios para responder antes de ocho minutos, teniendo en cuenta su ubicación, número y tipo. Métodos: Se obtuvo una base de datos de incidentes reportados en registros administrativos de la autoridad sanitaria distrital de Bogotá (de 2014 a 2017). A partir de esa información, se diseñó un modelo híbrido basado en la simulación de eventos discretos y algoritmos genéticos para establecer la cantidad, tipo y ubicación geográfica de recursos, conforme a frecuencias y tipología de los eventos. Resultados: De la base de datos, Bogotá presentó 938 671 envíos de ambulancias en el período. El 47,4% de prioridad alta, 18,9% media y 33,74% baja. El 92% de estos correspondieron a 15 de 43 códigos de emergencias médicas. Los tiempos de respuesta registrados fueron mayores a lo esperado, especialmente en paro cardiaco extra hospitalario (mediana de 19 minutos). En el modelo planteado, el mejor escenario requirió al menos 281 ambulancias, medicalizadas y básicas en proporción de 3:1 respectivamente para responder en tiempos adecuados. Conclusiones: Los resultados sugieren la necesidad de incrementar los recursos que responden a estos incidentes para acercar estos tiempos de respuesta a las necesidades de nuestra población.

Uso de simulación de eventos discretos y algoritmos genéticos para estimar los recursos necesarios para responder oportunamente en el sistema de emergencias médicas en Bogotá / Use of discrete event simulation and genetic algorithms to estimate the necessary resources to respond in a timely manner in the Medical Emergency System in Bogotá

INTRODUCCIÓN: Bogotá cuenta con un sistema de emergencias médicas de ambulancias públicas y privadas que responden a incidentes de salud. No se conoce, sin embargo, su suficiencia en cantidad, tipo y ubicación de recursos demandados. OBJETIVOS: A partir de los datos del sistema de emergencias médicas de Bogotá, Colombia, se buscó primero caracterizar la respuesta pre hospitalaria en paro cardiaco. Luego, con el modelo se buscó determinar cuál sería el menor número de recursos necesarios para responder antes de ocho minutos, teniendo en cuenta su ubicación, número y tipo. MÉTODOS: Se obtuvo una base de datos de incidentes reportados en registros administrativos de la autoridad sanitaria distrital de Bogotá (de 2014 a 2017). A partir de esa información, se diseñó un modelo híbrido basado en la simulación de eventos discretos y algoritmos genéticos para establecer la cantidad, tipo y ubicación geográfica de recursos, conforme a frecuencias y tipología de los eventos. RESULTADOS: De la base de datos, Bogotá presentó 938 671 envíos de ambulancias en el período. El 47,4% de prioridad alta, 18,9% media y 33,74% baja. El 92% de estos correspondieron a 15 de 43 códigos de emergencias médicas. Los tiempos de respuesta registrados fueron mayores a lo esperado, especialmente en paro cardiaco extra hospitalario (mediana de 19 minutos). En el modelo planteado, el mejor escenario requirió al menos 281 ambulancias, medicalizadas y básicas en proporción de 3:1 respectivamente para responder en tiempos adecuados. CONCLUSIONES: Los resultados sugieren la necesidad de incrementar los recursos que responden a estos incidentes para acercar estos tiempos de respuesta a las necesidades de nuestra población.

INTRODUCTION: Bogotá has a Medical Emergency System of public and private ambulances that respond to health incidents. However, its sufficiency in quantity, type and location of the resources demanded is not known. OBJECTIVE: Based on the data from the Medical Emergency System of Bogotá, Colombia, we first sought to characterize the prehospital response in cardiac arrest and determine with the model which is the least number of resources necessary to respond within eight minutes, taking into account their location, number, and type. METHODS: A database of incidents reported in administrative records of the district health authority of Bogotá (2014 to 2017) was obtained. Based on this information, a hybrid model based on discrete event simulation and genetic algorithms was designed to establish the amount, type and geographic location of resources according to the frequencies and typology of the events. RESULTS: From the database, Bogotá presented 938 671 ambulances dispatches in the period. 47.4% high priority, 18.9% medium and 33.74% low. 92% of these corresponded to 15 of 43 medical emergency codes. The response times recorded were longer than expected, especially in out-of-hospital cardiac arrest (median 19 minutes). In the proposed model, the best scenario required at least 281 ambulances, medicalized and basic in a 3:1 ratio, respectively, to respond in adequate time. CONCLUSIONS: Results suggest the need for an increase in the resources that respond to these incidents to bring these response times to the needs of our population.

Highest Defoliation Tolerance in Amaranthus cruentus Plants at Panicle Development Is Associated With Sugar Starvation Responses.

Defoliation tolerance (DT) in Amaranthus cruentus is known to reach its apex at the panicle emergence (PE) phase and to decline to minimal levels at flowering (FL). In this study, defoliation-induced changes were recorded in the content of non-structural carbohydrates and raffinose family oligosaccharides (RFOs), and in the expression and/or activity of sugar starvation response-associated genes in plants defoliated at different vegetative and reproductive stages. This strategy identified sugar-starvation-related factors that explained the opposite DT observed at these key developmental stages. Peak DT at PE was associated with increased cytosolic invertase (CI) activity in all organs and with the extensive induction of various class II trehalose-phosphate synthase (TPS) genes. Contrariwise, least DT at FL coincided with a sharp depletion of starch reserves and with sucrose (Suc) accumulation, in leaves and stems, the latter of which was consistent with very low levels of CI and vacuolar invertase activities that were not further modified by defoliation. Increased Suc suggested growth-inhibiting conditions associated with altered cytosolic Suc-to-hexose ratios in plants defoliated at FL. Augmented cell wall invertase activity in leaves and roots, probably acting in a regulatory rather than hydrolytic role, was also associated with minimal DT observed at FL. The widespread contrast in gene expression patterns in panicles also matched the opposite DT observed at PE and FL. These results reinforce the concept that a localized sugar starvation response caused by C partitioning is crucial for DT in grain amaranth.

Realocação de servidores públicos ante um processo de terceirização: estudo de caso em um restaurante universitário de uma universidade pública brasileira / Reallocation of public servants due to an outsourcing process: a case study in a Brazilian public university restaurant

Resumo Objetivo: apresentar e analisar uma intervenção realizada para a realocação de servidores públicos, ocasionada por processo de terceirização das atividades operacionais de um restaurante universitário de uma universidade pública brasileira. Métodos: estudo qualitativo descritivo. Foram realizadas análise documental e organizacional, entrevistas semiestruturadas e aplicação do Índice de Capacidade do Trabalho com 33 funcionários, em 2016. Resultados: o levantamento de informações referentes ao estado de saúde dos funcionários e a análise das exigências físicas das tarefas prescritas nos cargos a serem assumidos possibilitou a adequação da realocação para as novas funções de forma a não prejudicar os trabalhadores que já apresentavam restrições médicas e de garantir novas funções compatíveis com a capacidade laboral dos trabalhadores deslocados e dos que permaneceram na atividade original reestruturada. Conclusão: o estudo mostrou que, antes de fazer uma realocação, é importante analisar e compreender o trabalho realizado pelo indivíduo e envolver todos os atores implicados no processo de adaptação às novas funções.

Abstract Objective: to present and analyze an intervention undertaken to plan the reallocation of public servants replaced by an outsourcing process in a Brazilian public university restaurant. Methods: qualitative and descriptive study. We performed documentary and organizational analysis, carried out semi-structured interviews, and applied the Work Ability Index, in 33 employees, in 2016. Results: the gathering of information regarding the workers' health status, and the analysis of the physical requirements for the envisaged tasks of the positions to be assumed, made it possible to adapt the reallocation to the new functions. It made also possible not to harm the displaced workers who already had medical restrictions, and ensure them with new functions that were compatible with their working ability, or to jeopardize the ones who remained in the original restructured activity. Conclusion: the study indicates that before carrying out reallocation it is important to analyse and understand the work produced by the individual and to involve all implicated actors in the adaptation process for the new roles.

Computational Model for Microgeneration Simulation, From Solar and Wind Renewable Sources, With Optimal Allocation of Loads, Electric Vehicle and Energy Storage, In a Residential Electrical Micro Network

Abstract The electrical sector is under constant evolution. One of the areas refers to the consumers that come to be generators, implementing distributed generation, interconnected to a smart grid. This article discusses the improvement of an algorithm, already presented in the literature, to make the best temporal allocation of loads, electric vehicle, storage and many sources of generation, aiming at the maximum financial performance, that is, the lowest value for the energy invoice The modeling consists of a Mixed Integer Linear Programming (MILP) algorithm, which considers each component of the system and weighs the maintenance and shelf life of storage devices, basically batteries, loads that can be reallocated and the concept of Vehicle-to-grid, performing a daily analysis. The simulation has considered the hypothetical case of a residence, in which are included storage, electric vehicle and redistribution of loads, as well as wind and solar generation. Several scenarios are simulated, with or without the presence of some of the components. The results indicate that the simplest model, only redistributing the loads, can provide a sensible monetary savings of approximately 60%, while with the application of all the components modeled, there can be a reduction in the invoice of 90%.

Avaliação do risco da alocação de água em período de escassez hídrica: o caso do Sistema Jaguaribe-Metropolitano / Risk assessment of water allocation on water scarcity period: the case of Jaguaribe-Metropolitan System

RESUMO O artigo avalia a transferência de risco de uma política de alocação de água entre dois setores usuários: abastecimento urbano e irrigação. Para isso, a alocação entre usos foi realizada utilizando dois métodos: rateio linear e rateio com prioridades (adotado em períodos de escassez hídrica). O volume disponível para alocação foi obtido utilizando duas estratégias de operação de reservatórios: vazão afluente zero no segundo semestre do ano e previsão de vazão. Os ganhos e perdas dos setores usuários foram determinados por meio de funções benefícios. Os dois cenários de alocação apontaram garantias e benefícios menores para setor usuário de menor prioridade. O sistema de prioridade revelou que as infraestruturas de transferências hídricas proporcionam ganhos ao garantir a segurança hídrica para o setor prioritário, porém causam perdas quando extinguem o direito de uso da demanda de menor prioridade, indicando que a alocação de água também é um processo de distribuição de risco. A transferência de risco desse setor, tanto volumétrica quanto monetária, pode ser minimizada com o uso da informação climática. Uma alternativa para a alocação de água em ambientes com sistema de transferência hídrica seria definir um risco aceitável com vistas a aumentar o nível atual de benefícios da irrigação e a satisfação do abastecimento urbano. Esse risco pode ser estabelecido com base em modelos de previsão climática sazonal.

ABSTRACT The article evaluates the transfer of risk of a water allocation policy between two user sectors: urban supply and irrigation. The allocation between uses was performed using two methods: linear apportionment and assessment with priorities (adopted in periods of water scarcity). The amount available for allocation was obtained using two reservoir operation strategies: zero inflow in the second half of the year and forecast flow. Gains and losses of the user sectors were determined through benefits functions. The two allocation scenarios pointed to lower guarantees and benefits for user sector with less priority. The priority system revealed that the water transfer infrastructures provide gains for the higher priority sector when guaranteeing water security; however, cause losses when extinguishes the right to use the demand of lower priority, indicating that the allocation of water is also a distribution process risk. The transfer risk of this sector, volumetric and monetary, can be minimized with the use of climate information. Thus, an alternative to the allocation of water in environments with water transfer systems would be an acceptable risk in order to increase the current level of benefits of irrigation and the satisfaction of the urban supply. This risk can be established based on seasonal climate prediction models.