Primary prevention of rheumatic fever in the 21st century: evaluation of a national programme.

Background: Acute rheumatic fever (ARF) has largely disappeared from high-income countries. However, in New Zealand (NZ) rates remain high in indigenous (Maori) and Pacific populations. In 2011, NZ launched an intensive and unparalleled primary Rheumatic Fever Prevention Programme (RFPP). We evaluated the impact of the school-based sore throat service component of the RFPP. Methods: The evaluation used national trends of all-age first episode ARF hospitalisation rates before (2009-11) and after (2012-16) implementation of the RFPP. A retrospective cohort study compared first-episode ARF incidence during time-not-exposed (23 093 207 person-days) and time-exposed (68 465 350 person-days) with a school-based sore throat service among children aged 5-12 years from 2012 to 2016. Results: Following implementation of the RFPP, the national ARF incidence rate declined by 28% from 4.0 per 100 000 [95% confidence interval (CI) 3.5-4.6] at baseline (2009-11) to 2.9 per 100 000 by 2016 (95% CI 2.4-3.4, P <0.01). The school-based sore throat service effectiveness overall was 23% [95% CI -6%-44%; rate ratio (RR) 0.77, 95% CI 0.56-1.06]. Effectiveness was greater in one high-risk region with high coverage (46%, 95% CI 16%-66%; RR 0.54, 95% CI 0.34-0.84). Conclusions: Population-based primary prevention of ARF through sore throat management may be effective in well-resourced settings like NZ where high-risk populations are geographically concentrated. Where high-risk populations are dispersed, a school-based primary prevention approach appears ineffective and is expensive.

Direct medical costs of hospitalizations for cardiovascular diseases in Shanghai, China: trends and projections.

Few studies in China have focused on direct expenditures for cardiovascular diseases (CVDs), making cost trends for CVDs uncertain. Epidemic modeling and forecasting may be essential for health workers and policy makers to reduce the cost burden of CVDs.To develop a time series model using Box-Jenkins methodology for a 15-year forecasting of CVD hospitalization costs in Shanghai.Daily visits and medical expenditures for CVD hospitalizations between January 1, 2008 and December 31, 2012 were analyzed. Data from 2012 were used for further analyses, including yearly total health expenditures and expenditures per visit for each disease, as well as per-visit-per-year medical costs of each service for CVD hospitalizations. Time series analyses were performed to determine the long-time trend of total direct medical expenditures for CVDs and specific expenditures for each disease, which were used to forecast expenditures until December 31, 2030.From 2008 to 2012, there were increased yearly trends for both hospitalizations (from 250,354 to 322,676) and total costs (from US $ 388.52 to 721.58 million per year in 2014 currency) in Shanghai. Cost per CVD hospitalization in 2012 averaged US $ 2236.29, with the highest being for chronic rheumatic heart diseases (US $ 4710.78). Most direct medical costs were spent on medication. By the end of 2030, the average cost per visit per month for all CVDs was estimated to be US $ 4042.68 (95% CI: US $ 3795.04-4290.31) for all CVDs, and the total health expenditure for CVDs would reach over US $1.12 billion (95% CI: US $ 1.05-1.19 billion) without additional government interventions.Total health expenditures for CVDs in Shanghai are estimated to be higher in the future. These results should be a valuable future resource for both researchers on the economic effects of CVDs and for policy makers.

Primary prevention of acute rheumatic fever and rheumatic heart disease with penicillin in South African children with pharyngitis: a cost-effectiveness analysis.

BACKGROUND: Acute rheumatic fever and subsequent rheumatic heart disease remain significant in developing countries. We describe a cost-effective analysis of 7 strategies for the primary prevention of acute rheumatic fever and rheumatic heart disease in children presenting with pharyngitis in urban primary care clinics in South Africa. METHODS AND RESULTS: We used a Markov model to assess the cost-effectiveness of treatment with intramuscular penicillin using each of the following strategies: (1) empirical (treat all); (2) positive throat culture (culture all); (3) clinical decision rule (CDR) score ≥2 (CDR 2+); (4) CDR score ≥3 (CDR 3+); (5) treating those with a CDR score ≥2 plus those with CDR score <2 and positive cultures (CDR 2+, culture CDR negatives); (6) treating those with a CDR score ≥3 plus those with CDR score <3 and positive cultures (CDR 3+, culture CDR negatives); and (7) treat none. The strategies ranked in order from lowest cost were treat all ($11.19 per child), CDR 2+ ($11.20); the CDR 3+ ($13.00); CDR 2+, culture CDR negatives ($16.42); CDR 3+, culture CDR negatives ($23.89); and culture all ($27.21). The CDR 2+ is the preferred strategy at less than $150/quality-adjusted life year compared with the treat all strategy. A strategy of culturing all children compared with the CDR 2+ strategy costs more than $125 000/quality-adjusted life year gained. CONCLUSIONS: Treating all children presenting with pharyngitis in urban primary care clinics in South Africa with intramuscular penicillin is the least costly. A strategy of using a clinical decision rule without culturing is overall the preferred strategy. A strategy of culturing all children may be prohibitively expensive.

Mortality and hospitalisation costs of rheumatic fever and rheumatic heart disease in New Zealand.

AIMS: To estimate the annual mortality and the cost of hospital admissions for acute rheumatic fever (ARF) and rheumatic heart disease (RHD) for New Zealand residents. METHODS: Hospital admissions in 2000-2009 with a principal diagnosis of ARF or RHD (ICD9_AM 390-398; ICD10-AM I00-I099) and deaths in 2000-2007 with RHD as the underlying cause were obtained from routine statistics. The cost of each admission was estimated by multiplying its diagnosis-related group (DRG) cost weight by the national price for financial year 2009/2010. RESULTS: There were on average 159 RHD deaths each year with a mean annual mortality rate of 4.4 per 100, 000 (95% confidence limit 4.2, 4.7). Age-adjusted mortality was five- to 10-fold higher for Maori and Pacific peoples than for non-Maori/Pacific. The mean age at RHD death (male/female) was 56.4/58.4 for Maori, 50.9/59.8 for Pacific and 78.2/80.6 for non-Maori, non-Pacific men and women. The average annual DRG-based cost of hospital admissions in 2000-2009 for ARF and RHD across all age groups was $12.0 million (95% confidence limit $11.1 million, $12.8 million). Heart valve surgery accounted for 28% of admissions and 71% of the cost. For children 5-14 years of age, valve surgery accounted for 7% of admissions and 27% of the cost. Two-thirds of the cost occurs after the age of 30. CONCLUSIONS: ARF and RHD comprise a burden of mortality and hospital cost concentrated largely in middle age. Maori and Pacific RHD mortality rates are substantially higher than those of non-Maori/Pacific.

Indirect cost-effectiveness analyses of abatacept and rituximab in patients with moderate-to-severe rheumatoid arthritis in the United States.

OBJECTIVE: To estimate the incremental cost per quality-adjusted life-years (QALYs) for abatacept and rituximab, in combination with methotrexate, relative to methotrexate alone in patients with active rheumatoid arthritis (RA). METHODS: A patient-level simulation model was used to depict the progression of functional disability over the lifetimes of women aged 55-64 years with active RA and inadequate response to a tumor necrosis factor (TNF)-alpha antagonist therapy. Future health-state utilities and medical care costs were based on projected values of the Health Assessment Questionnaire Disability Index (HAQ-DI). Patients were assumed to receive abatacept or rituximab in combination with methotrexate until death or therapy discontinuation due to lack of efficacy or adverse events. HAQ-DI improvement at month 6, after adjustments for control drug (methotrexate) response, was derived from two clinical trials. Costs of medical care and biologic drugs, discounted at 3% annually, were from the perspective of a US third-party payer and expressed in 2007 US dollars. RESULTS: Relative to methotrexate alone, abatacept/methotrexate and rituximab/methotrexate therapies were estimated to yield an average of 1.25 and 1.10 additional QALYs per patient, at mean incremental costs of $58,989 and $60,380, respectively. The incremental cost-utility ratio relative to methotrexate was $47,191 (95% CI $44,810-49,920) per QALY gained for abatacept/methotrexate and $54,891 (95% CI $52,274-58,073) per QALY gained for rituximab/methotrexate. At an acceptability threshold of $50,000 per QALY, the probability of cost effectiveness was 90% for abatacept and 0.0% for rituximab. CONCLUSION: Abatacept was estimated to be more cost effective than rituximab for use in RA from a US third-party payer perspective. However, head-to-head clinical trials and long-term observational data are needed to confirm these findings.

Prevention and control of rheumatic fever and rheumatic heart disease: the Cuban experience (1986-1996-2002).

BACKGROUND: Rheumatic fever (RF) and rheumatic heart disease (RHD) are still major medical and public health problems mainly in developing countries. Pilot studies conducted during the last five decades in developed and developing countries indicated that the prevention and control of RF/RHD is possible. During the 1970s and 1980s, epidemiological studies were carried out in selected areas of Cuba in order to determine the prevalence and characteristics of RF/RHD, and to test several long-term strategies for prevention of the diseases. METHODS: Between 1986 and 1996 we carried out a comprehensive 10-year prevention programme in the Cuban province of Pinar del Rio and evaluated its efficacy five years later. The project included primary and secondary prevention of RF/RHD, training of personnel, health education, dissemination of information, community involvement and epidemiological surveillance. Permanent local and provincial RF/RHD registers were established at all hospitals, policlinics and family physicians in the province. Educational activities and training workshops were organised at provincial, local and health facility level. Thousands of pamphlets and hundreds of posters were distributed, and special programmes were broadcast on the public media to advertise the project. RESULTS: There was a progressive decline in the occurrence and severity of acute RF and RHD, with a marked decrease in the prevalence of RHD in school children from 2.27 patients per 1,000 children in 1986 to 0.24 per 1,000 in 1996. A marked and progressive decline was also seen in the incidence and severity of acute RF in five- to 25-year-olds, from 18.6 patients per 100,000 in 1986 to 2.5 per 100,000 in 1996. There was an even more marked reduction in recurrent attacks of RF from 6.4 to 0.4 patients per 100,000, as well as in the number and severity of patients requiring hospitalisation and surgical care. Regular compliance with secondary prophylaxis increased progressively and the direct costs related to treatment of RF/RHD decreased with time. The implementation of the programme did not incur much additional cost for healthcare. Five years after the project ended, most of the measures initiated at the start of the programme were still in place and occurrence of RF/RHD was low.

Characteristics of children discharged from hospitals in the United States in 2000 with the diagnosis of acute rheumatic fever.

OBJECTIVE: The goal was to describe characteristics of children discharged from hospitals in the United States in 2000 with the diagnosis of acute rheumatic fever. METHODS: We explored characteristics of children <21 years of age who were hospitalized with a diagnosis of acute rheumatic fever by using the 2000 Kids' Inpatient Database, weighted to estimate the number and rate of acute rheumatic fever-associated hospitalizations in the United States. RESULTS: In 2000, an estimated 503 acute rheumatic fever hospitalizations occurred among children <21 years of age, at a rate of 14.8 cases per 100,000 hospitalized children, with a mean age of 10 years. In comparison with all Kids' Inpatient Database admissions, acute rheumatic fever hospitalizations were more common in the age group of 6 to 11 years and among male patients. Chorea was more common in female patients (61.7%). White patients were significantly underrepresented, whereas Asian/Pacific Islander patients and patients of other races were overrepresented. Hospitalizations of patients with acute rheumatic fever were significantly more common in the Northeast and less common in the South. The highest rates of acute rheumatic fever hospitalizations occurred in Utah, Hawaii, Pennsylvania, and New York. Significantly more acute rheumatic fever admissions occurred in March. The expected payor was more likely to be private insurance and less likely to be Medicaid. Acute rheumatic fever hospitalizations were more likely to occur in teaching hospitals, freestanding children's hospitals, and children's units in general hospitals and in urban locations. The median length of stay for acute rheumatic fever hospitalizations was 3 days, and the median total charges were $6349. The in-hospital mortality rate was 0.6%. CONCLUSIONS: In 2000, we found that hospitalizations for acute rheumatic fever were infrequent and varied according to race, season, location, and type of hospital.

Rheumatic fever and rheumatic heart disease: primary prevention is the cost effective option.

OBJECTIVE: To measure the economic output/input ratios for the various options of prevention of rheumatic fever/rheumatic heart disease (RF/RHD) and check the viability of primary prevention vis-à-vis secondary and tertiary preventions. METHODS: Cost accounting of the various prevention options was calculated for each variable as available in literature. Actual data as obtainable for the financial year ending March 2006 were computed for the Pondicherry population. Both direct and indirect costs (including community/social costs) were worked out using mostly primary data and wherever necessary, secondary data. Certain scientific assumptions were used where exact data was not available. RESULTS: Primary prevention is the definite viable economic option (1:1.56) compared to secondary (1: 1.07) and tertiary (1: 0.12) preventions. In fact, the current stress on only secondary and tertiary preventions is found to be economically unviable. CONCLUSION: It is postulated that primary prevention as a practical policy in tackling RF and RHD can be recommended.

Diagnosis and management of pharyngitis in a pediatric population based on cost-effectiveness and projected health outcomes.

BACKGROUND: Pharyngitis is a common childhood complaint. Current management for children and adolescents includes 1 of 6 strategies, ie, (1) observe without testing or treatment, (2) treat all suspected cases with an antibiotic, (3) treat those with positive throat cultures, (4) treat those with positive rapid tests, (5) treat those with positive rapid tests and those with positive throat cultures after negative rapid tests, or (6) use a clinical scoring measure to determine the diagnosis/treatment strategy. The sequelae of untreated group A hemolytic streptococcal (GAS) pharyngitis are rare, whereas antibiotic treatment may result in side effects ranging from rash to death. The cost-utility of these strategies for children has not been reported previously. METHODS: A decision tree analysis incorporating the total cost and health impact of each management strategy was used to determine cost per quality-adjusted life-year ratios. Sensitivity analyses and Monte Carlo simulations assessed the accuracy of the estimates. RESULTS: From a societal perspective with current Medicaid reimbursements for testing, performing a throat culture for all patients had the best cost-utility. For private insurance reimbursements, rapid antigen testing had the best cost-utility. Observing without testing or treatment had the lowest morbidity rate and highest cost from a societal perspective but the lowest cost from a payer perspective. The model was most sensitive to the incidence of acute rheumatic fever and peritonsillar abscess after untreated GAS pharyngitis. Monte Carlo simulations demonstrated considerable overlap among all of the options except for treating all patients and observing all patients. CONCLUSIONS: Observing patients with pharyngitis had the lowest morbidity rate. The costs of this option were primarily from parental time lost from work. Before recommending observation rather than treatment of GAS pharyngitis, accurate estimates of the risk of developing acute rheumatic fever and peritonsillar abscess after GAS pharyngitis are needed.

Diagnosis and management of adults with pharyngitis. A cost-effectiveness analysis.

BACKGROUND: Rheumatic fever has become uncommon in the United States while rapid diagnostic test technology for streptococcal antigens has improved. However, little is known about the effectiveness or cost-effectiveness of various strategies for managing pharyngitis caused by group A beta-hemolytic streptococcus (GAS) in U.S. adults. OBJECTIVE: To examine the cost-effectiveness of several diagnostic and management strategies for patients with suspected GAS pharyngitis. DESIGN: Cost-effectiveness analysis. DATA SOURCES: Published literature, including systematic reviews where possible. When costs were not available in the literature, we estimated them from our institution and Medicare charges. TARGET POPULATION: Adults in the general U.S. population. TIME HORIZON: 1 year. PERSPECTIVE: Societal. INTERVENTIONS: Five strategies for the management of adult patients with pharyngitis: 1) observation without testing or treatment, 2) empirical treatment with penicillin, 3) throat culture using a two-plate selective culture technique, 4) optical immunoassay (OIA) followed by culture to confirm negative OIA test results, or 5) OIA alone. OUTCOME MEASURES: Cost per lost quality-adjusted life-days (converted to life-years where appropriate) and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: Empirical treatment was the least effective strategy at a GAS pharyngitis prevalence of 10% (resulting in 0.41 lost quality-adjusted life-day). Although the other four strategies had similar effectiveness (all resulted in about 0.27 lost quality-adjusted life-day), culture was the least expensive strategy. RESULTS OF SENSITIVITY ANALYSES: Results were sensitive to the prevalence of GAS pharyngitis: OIA followed by culture was most effective when GAS pharyngitis prevalence was greater than 20%. Observation was least expensive when prevalence was less than 6%, and empirical treatment was least expensive when prevalence was greater than 71%. The effectiveness of strategies was also very sensitive to the probability of anaphylaxis: When the probability of anaphylaxis was about half the baseline probability, OIA/culture was most effective; when the probability was 1.6 times that of baseline, observation was most effective. Only at an OIA cost less than half of baseline did the OIA alone strategy become less expensive than culture. Results were not sensitive to other variations in probabilities or costs of diagnosis or treatment of GAS pharyngitis. CONCLUSIONS: Observation, culture, and two rapid antigen test strategies for diagnostic testing and treatment of suspected GAS pharyngitis in adults have very similar effectiveness and costs, although culture is the least expensive and most effective strategy when the GAS pharyngitis prevalence is 10%. Empirical treatment was not the most effective or least expensive strategy at any prevalence of GAS pharyngitis in adults, although it may be reasonable for individual patients at very high risk for GAS pharyngitis as assessed by a clinical decision rule.

The costs of musculoskeletal disease: health needs assessment and health economics.

Arthritis and musculoskeletal conditions dominate the national illness burden worldwide. This chapter presents information on the different types of societal and individual impacts of musculoskeletal conditions, and describes the appropriate way to evaluate and present these effects. There are three types of 'costs' associated with musculoskeletal conditions: direct, indirect and intangible. The direct costs of care are those associated with ambulatory and inpatient medical care; these costs may be borne by the patient or society. The indirect costs are those paid and unpaid activities, such as employment, schooling and homemaking, that result from disability associated with the health condition; these costs may be borne by employers, society or the individual patient. The intangible costs of the disease are pain, emotional impairment, health worry and other effects on the patient's quality of life. All of these components of costs may, and should be, accurately measured to get the full picture of the burden of musculoskeletal conditions.

Will genetic testing alter the management of disease caused by infectious agents? A cost-effectiveness analysis of gene-testing strategies for prevention of rheumatic Fever.

Cost-effectiveness analysis was done to evaluate the potential health and economic effects of a genetic screening program to identify individuals at risk for rheumatic fever (RF). The current RF prevention strategy was compared with a new, primary prevention strategy involving early genetic testing and intensive prophylaxis to prevent a first attack among individuals at high risk for RF. When analysis of a hypothetical 2000 birth cohort was done from a societal perspective, the prevention strategy involving genetic screening and prophylaxis for high-risk persons reduced the number of RF cases and increased life span at an estimated discounted cost of $7900 per quality-adjusted life-year gained. Genetic screening became the preferred (least expensive) strategy if the test specificity was >/=98%, the annual cost of prophylaxis was <$550, or the annual cost of caring for an individual with severe rheumatic heart disease increased to >$32,000. When used with available antibiotic prophylaxis, genetic testing has the potential to provide a cost-effective strategy for the primary prevention of RF and its sequelae.

Resource utilization and cost of rheumatic fever.

OBJECTIVE: The socioeconomic effects of rheumatic fever (RF) in Brazil, including direct and indirect costs to patients and their families and to society, are largely unknown. We evaluated the utilization of resources and costs related to RF in a tertiary center caring for low income patients in the city of São Paulo, Brazil. METHODS: One hundred patients with RF, younger than 18 yrs, with followup of at least one year, were sequentially selected to provide complete information on a questionnaire. Additional data were collected from patients' charts. The utilization of resources was evaluated for each patient throughout the entire disease course. Costs were determined for patients and their families as well as for the society, using variables from 3 different systems: the national public health system, used by most lower income groups; the Brazilian Medical Association, which regulates charges and fees utilized by health plans and insurance companies; and costs charged by private practitioners, paid directly by patients. RESULTS: The RF population studied belonged to a low socioeconomic level. The mean monthly family income was $625.20 US. The mean disease duration was 3.9 yrs (range 1-10). Patients had a total of 1657 medical consultations, 22 hospital admissions, and 4 admissions to intensive care unit. Work absenteeism among parents was calculated as 22.9%, equivalent to 901 days of missed work; about 5% of the parents lost their jobs. Patients showed a high rate of school failure (22%). Considering the public system as a reference, direct, indirect, and total costs to society per 100 patients throughout the entire disease duration were $105,860 US ($271/patient/yr), $18,803 US ($48/patient/yr), and $124,663 US (US $319/patient/yr), respectively. When health care plan and private systems were taken as reference, the total costs were $423,550 US and $684,351 US, respectively. CONCLUSION: RF and rheumatic heart disease have an important socioeconomic impact in Brazil; costs of RF made up roughly 1.3% of annual family income. The estimated annual cost of RF for society in Brazil is $51,144,347.00 US.

Management of sore throats in children: a cost-effectiveness analysis.

OBJECTIVE: To perform a cost-effectiveness analysis of treatment management strategies for children older than 3 years who present with signs or symptoms of pharyngitis. DESIGN: Decision model with 7 strategies, including neither testing for streptococcus nor treating with antibiotics; treating empirically with penicillin V; basing treatment on results of a throat culture (Culture); and basing treatment on results of enzyme immunoassay or optical immunoassay rapid tests, performed alone or in combination with throat cultures. In these 7 strategies, all tests are performed in a local reference laboratory. In a sensitivity analysis, we examined the cost-effectiveness of 4 strategies involving office-based testing. We obtained data on event probabilities and test characteristics from our hospital's clinical laboratory and the literature; costs for the analysis were based on resource use. RESULTS: At a baseline prevalence of 20.8% for streptococcal pharyngitis, the Culture strategy was the least expensive and most effective, with an average cost of $6.85 per patient. The outcome was sensitive to the prevalence of streptococcal pharyngitis, the rheumatic fever attack rate, the cost of the enzyme immunoassay test, and the cost of culturing and reporting culture results. The Culture strategy was also preferred if amoxicillin was substituted for oral penicillin. For office-based testing, Culture was the least costly strategy, but treatment based on results of the optical immunoassay test alone had an incremental cost-effectiveness ratio of $1.6 million per additional life saved. CONCLUSION: In a setting with adherent patients, children with sore throats should generally get throat cultures in lieu of rapid streptococcus antigen tests.

Utilização de recursos e custos de pacientes com febre reumática / Utilization of resources and costs of patients with rheumatic fever

Introdução A FR é a afecção cardiovascular adquirida mais freqüente e importante na infância e permanece um problema de saúde pública nos países em desenvolvimento, com impactos financeiros na família e na sociedade. Entre famílias de nível sócio-econômico mais baixo que vivem em condições de superpopulação, a sua incidência se aproxima de 100/100000 crianças. Pelo fato da FR ser uma doença muitop freqüente em nosso meio, o que acarreta gastos excessivos e desnecessários com o tratamento, que seriam menores caso houvesse uma prevenção adequada e ainda pela falta de dados de estudos no Brasil, nos propusemos a realizar um trabalho sobre o impacto sócio-econômico da FR em uma população de crianças e adolescentes acompanhadas no serviço de Reumatologia do setor de Alergia, Imunologia e Reumatologia do departamento de Pediatria da UNIFESP - EPM. Casuística e métodos Foram selecionados consecutivamente 100 pacientes com FR que preenchiam os critérios de Jones modificados. Os requisitos para inclusão foram: 1) idade de até 18 anos imcompletos; 2) período mínimo de seguimento no nosso ambulatório de 12 meses; 3) apresentar condições de fornecer informações confiáveis às perguntas contidas no questionário; 4) possuir prontuário médico disponível e completo para compilação dos dados necessários. A determinação do custo de cada ítem isolado foi realizada de acordo com três diferentes sistemas de custeio (Sistema Único de Saúde, Associação Médica Brasileira e Particular) e computado para o paciente e para a sociedade. Resultados Dos 100 pacientes estudados, 11 apresentaram recorrências. No primeiro surto a artrite ocorreu em 68, cardite em 49 e coréia em 32 casos. A valvuloplastia mais freqüente foi de insuficiência mitral (92,2(por cento) das valvuloplastias). A estenose mitral (lesão de seqüela) ocorreu em 23 pacientes. Falhas na profilaxia com penicilina ocorreram em 36,4(por cento). A situação sócio-econômica mostrou nível baixo com renda familiar média de 719 reais, número médio de dependentes de 5,1 e índice de analfabetismo dos pais de 16(por cento). Os pacientes tiveram 1657 consultas e 22 internações de enfermaria e 4 de UTI. Dois pacientes foram submetidos a cirurgia cardíaca (total de três cirurgias). Cerca de 23(por cento) de pais ou mães perderam dias de trabalho em um total de 901 dias. Cerca de 5(por cento) perderam o emprego. Oitenta e quatro pacientes perderam 1812 dias de aulas e houve 22 casos de repetência. Foram...(au)