RESUMEN
OBJECTIVES: To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications. STUDY DESIGN: Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges. RESULTS: We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P < .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke). CONCLUSIONS: Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children.
Asunto(s)
Apendicitis/complicaciones , Cetoacidosis Diabética/complicaciones , Servicio de Urgencia en Hospital/estadística & datos numéricos , Utilización de Instalaciones y Servicios/estadística & datos numéricos , Enfermedades del Ovario/complicaciones , Torsión del Cordón Espermático/complicaciones , Accidente Cerebrovascular/complicaciones , Enfermedad Aguda , Adolescente , Apendicitis/economía , Apendicitis/epidemiología , Apendicitis/terapia , Niño , Preescolar , Bases de Datos Factuales , Cetoacidosis Diabética/economía , Cetoacidosis Diabética/epidemiología , Cetoacidosis Diabética/terapia , Servicio de Urgencia en Hospital/economía , Utilización de Instalaciones y Servicios/economía , Femenino , Precios de Hospital/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Maryland/epidemiología , New York/epidemiología , Enfermedades del Ovario/economía , Enfermedades del Ovario/epidemiología , Enfermedades del Ovario/terapia , Prevalencia , Torsión del Cordón Espermático/economía , Torsión del Cordón Espermático/epidemiología , Torsión del Cordón Espermático/terapia , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/terapiaRESUMEN
OBJECTIVE: Few studies from low- and middle-income countries have assessed stroke and cerebral reperfusion costs from the private sector. To measure the in-hospital costs of ischemic stroke (IS), with and without cerebral reperfusion, primary intracerebral hemorrhage (PIH), subarachnoid hemorrhage (SAH) and transient ischemic attacks (TIA) in two private hospitals in Joinville, Brazil. METHODS: Prospective disease-cost study. All medical and nonmedical costs for patients admitted with any stroke type or TIA were consecutively determined in 2016-17. All costs were adjusted to the gross domestic product deflator index and purchasing power parity. RESULTS: We included 173 patients. The median cost per patient was US$3,827 (IQR: 2,800-8,664) for the 131 IS patients; US$2,315 (IQR: 1,692-2,959) for the 27 TIA patients; US$16,442 (IQR: 5,108-33,355) for the 11 PIH patients and US$28,928 (IQR: 12,424-48,037) for the four SAH patients (p < 0.00001). For the six IS patients who underwent intravenous thrombolysis, the median cost per patient was US$11,463 (IQR: 8,931-14,291), and for the four IS patients who underwent intra-arterial thrombectomy, the median cost per patient was US$35,092 (IQR: 31,833-37,626; p < 0.0001). A direct correlation was found between cost and length of stay (r = 0.67, p < 0.001). CONCLUSIONS: Stroke is a costly disease. In the private sector, the costs of cerebral reperfusion for IS treatment were three-to-ten times higher than for usual treatments. Therefore, cost-effectiveness studies are urgently needed in low- and middle-income countries.
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Costos de la Atención en Salud/estadística & datos numéricos , Hospitales Privados/economía , Tiempo de Internación/economía , Accidente Cerebrovascular/economía , Anciano , Anciano de 80 o más Años , Brasil , Hemorragia Cerebral/economía , Femenino , Humanos , Ataque Isquémico Transitorio/economía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Valores de Referencia , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Accidente Cerebrovascular/terapia , Hemorragia Subaracnoidea/economía , Factores de TiempoRESUMEN
OBJECTIVE: Low- and middle-income countries face tight health care budgets, not only new resources, but also costly therapeutic resources for treatment of ischemic stroke (IS). However, few prospective data about stroke costs including cerebral reperfusion from low- and middle-income countries are available. To measure the costs of stroke care in a public hospital in Joinville, Brazil. METHODS: We prospectively assessed all medical and nonmedical costs of inpatients admitted with a diagnosis of any stroke or transient ischemic attack over one year, analyzed costs per type of stroke and treatment, length of stay (LOS) and compared hospital costs with government reimbursement. RESULTS: We evaluated 274 patients. The total cost for the year was US$1,307,114; the government reimbursed the hospital US$1,095,118. We found a significant linear correlation between LOS and costs (r = 0.71). The median cost of 134 IS inpatients who did not undergo cerebral reperfusion (National Institutes of Health Stroke Scale [NIHSS] median = 3 ) was US$2,803; for IS patients who underwent intravenous (IV) alteplase (NIHSS 10), the median was US$5,099, and for IS patients who underwent IV plus an intra-arterial (IA) thrombectomy (NIHSS > 10), the median cost was US$10,997. The median costs of a primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack were US$2,436, US$8,031 and US$2,677, respectively. CONCLUSIONS: Reperfusion treatments were two-to-four times more expensive than conservative treatment. A cost-effectiveness study of the IS treatment option is necessary.
Asunto(s)
Costos de la Atención en Salud/estadística & datos numéricos , Hospitales Públicos/economía , Tiempo de Internación/economía , Accidente Cerebrovascular/economía , Adulto , Anciano , Anciano de 80 o más Años , Brasil , Hemorragia Cerebral/economía , Femenino , Humanos , Ataque Isquémico Transitorio/economía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Valores de Referencia , Estadísticas no Paramétricas , Hemorragia Subaracnoidea/economía , Factores de TiempoRESUMEN
ABSTRACT Few studies from low- and middle-income countries have assessed stroke and cerebral reperfusion costs from the private sector. Objective To measure the in-hospital costs of ischemic stroke (IS), with and without cerebral reperfusion, primary intracerebral hemorrhage (PIH), subarachnoid hemorrhage (SAH) and transient ischemic attacks (TIA) in two private hospitals in Joinville, Brazil. Methods Prospective disease-cost study. All medical and nonmedical costs for patients admitted with any stroke type or TIA were consecutively determined in 2016-17. All costs were adjusted to the gross domestic product deflator index and purchasing power parity. Results We included 173 patients. The median cost per patient was US$3,827 (IQR: 2,800-8,664) for the 131 IS patients; US$2,315 (IQR: 1,692-2,959) for the 27 TIA patients; US$16,442 (IQR: 5,108-33,355) for the 11 PIH patients and US$28,928 (IQR: 12,424-48,037) for the four SAH patients (p < 0.00001). For the six IS patients who underwent intravenous thrombolysis, the median cost per patient was US$11,463 (IQR: 8,931-14,291), and for the four IS patients who underwent intra-arterial thrombectomy, the median cost per patient was US$35,092 (IQR: 31,833-37,626; p < 0.0001). A direct correlation was found between cost and length of stay (r = 0.67, p < 0.001). Conclusions Stroke is a costly disease. In the private sector, the costs of cerebral reperfusion for IS treatment were three-to-ten times higher than for usual treatments. Therefore, cost-effectiveness studies are urgently needed in low- and middle-income countries.
RESUMO Poucos estudos determinam o custo do AVC em países de baixa e média renda nos setores privados. Objetivos Mensurar o custo hospitalar do tratamento do(a): AVC isquêmico com e sem reperfusão cerebral, hemorragia intracerebral primária (HIP), hemorragia subaracnóidea e ataque isquêmico transitório (AIT) em hospitais privados de Joinville, Brasil. Métodos Estudo prospectivo de custo de doença. Os custos médicos e não médicos dos pacientes admitidos com qualquer tipo de AVC ou AIT foram consecutivamente verificados em 2016-17. Os valores foram ajustados ao índice do deflator do produto interno bruto e à paridade do poder de compra. Resultados Nós incluímos 173 pacientes. A mediana de custo por paciente foi de US$ 3.827 (IQR: 2.800-8.664) para os 131 pacientes com AVC isquêmico; US$ 2.315 (1.692-2.959) para os 27 pacientes com AIT; US$ 16.442 (5.108-33.355) para os 11 pacientes com HIP e US$ 28.928 (12.424-48.037) para os quatro pacientes com HSA (p < 0,00001). Para seis pacientes submetidos à trombólise intravenosa, a mediana do custo por paciente foi de US$ 11.463 (8.931-14.291) e, para quatro pacientes submetidos à trombectomia intra-arterial, a mediana de custo por paciente foi de US$ 35.092 (31.833-37.626; p < 0,0001). Uma correlação direta foi encontrada entre custo e tempo de permanência (r = 0,67, p < 0,001). Conclusão O AVC é uma doença cara. Em ambiente privado, os custos da reperfusão cerebral foram de três a dez vezes superiores aos tratamentos habituais do AVC isquêmico. Portanto, estudos de custo-efetividade são urgentemente necessários em países de baixa e média rendas.
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Hospitales Privados/economía , Costos de la Atención en Salud/estadística & datos numéricos , Accidente Cerebrovascular/economía , Tiempo de Internación/economía , Valores de Referencia , Hemorragia Subaracnoidea/economía , Factores de Tiempo , Índice de Severidad de la Enfermedad , Brasil , Hemorragia Cerebral/economía , Ataque Isquémico Transitorio/economía , Estudios Prospectivos , Estadísticas no Paramétricas , Accidente Cerebrovascular/terapiaRESUMEN
ABSTRACT Low- and middle-income countries face tight health care budgets, not only new resources, but also costly therapeutic resources for treatment of ischemic stroke (IS). However, few prospective data about stroke costs including cerebral reperfusion from low- and middle-income countries are available. Objective To measure the costs of stroke care in a public hospital in Joinville, Brazil. Methods We prospectively assessed all medical and nonmedical costs of inpatients admitted with a diagnosis of any stroke or transient ischemic attack over one year, analyzed costs per type of stroke and treatment, length of stay (LOS) and compared hospital costs with government reimbursement. Results We evaluated 274 patients. The total cost for the year was US$1,307,114; the government reimbursed the hospital US$1,095,118. We found a significant linear correlation between LOS and costs (r = 0.71). The median cost of 134 IS inpatients who did not undergo cerebral reperfusion (National Institutes of Health Stroke Scale [NIHSS] median = 3 ) was US$2,803; for IS patients who underwent intravenous (IV) alteplase (NIHSS 10), the median was US$5,099, and for IS patients who underwent IV plus an intra-arterial (IA) thrombectomy (NIHSS > 10), the median cost was US$10,997. The median costs of a primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack were US$2,436, US$8,031 and US$2,677, respectively. Conclusions Reperfusion treatments were two-to-four times more expensive than conservative treatment. A cost-effectiveness study of the IS treatment option is necessary.
RESUMO Os países de baixa e media renda enfrentam orçamentos apertados na saúde, não somente devido aos novos recursos terapêuticos, mas relacionado ao custo oneroso do tratamento do acidente vascular cerebral. No entanto, poucos dados prospectivos sobre os custos do AVC, incluindo reperfusão cerebral de países de baixa e média renda estão disponíveis. Objetivo Mensurar os custos do atendimento ao AVC em um hospital público. Métodos Avaliamos prospectivamente todos os custos médicos e não médicos de pacientes internados com diagnóstico de acidente vascular cerebral ou AIT durante 1 ano, analisamos os custos por tipo de AVC e tratamento, tempo de permanência e comparamos os custos hospitalares com o reembolso governamental. Resultados Foram avaliados 274 pacientes. O custo total em um ano foi de US$ 1.307,114; o governo reembolsou o hospital no valor de US$ 1.095.118. Encontramos uma correlação linear significativa entre LOS e custos (r = 0,71). A mediana do custo do AVCI em 134 pacientes que não sofreram reperfusão cerebral (National Institutes of Health Stroke Scale [NIHSS] mediana = 3) foi de US$ 2.803; para pacientes submetidos a alteplase intravenosa (IV) (NIHSS 10), a mediana foi de US$ 5.099 e para os pacientes submetidos a trombectomia intra-arterial (IA) (NIHSS > 10), o custo mediano foi de US$ 10.997. A mediana do custo de uma hemorragia intracerebral primária, hemorragia subaracnóidea e AIT foram de US$ 2.436, US$ 8.031 e US$ 2.677, respectivamente. Conclusões Os tratamentos de reperfusão foram duas a quatro vezes mais caros do que o tratamento conservador. Estudo de custo-efetividade para o tratamento do AVC são necessários.
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Costos de la Atención en Salud/estadística & datos numéricos , Accidente Cerebrovascular/economía , Hospitales Públicos/economía , Tiempo de Internación/economía , Valores de Referencia , Hemorragia Subaracnoidea/economía , Factores de Tiempo , Brasil , Hemorragia Cerebral/economía , Ataque Isquémico Transitorio/economía , Estudios Prospectivos , Estadísticas no ParamétricasRESUMEN
Background Racial/ethnic disparities in acute stroke care may impact stroke outcomes. We compared outcomes by race/ethnicity among elderly Medicare beneficiaries in hospitals participating in the FL-PR CReSD (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities) registry with those in hospitals not participating in any quality improvement programs (non- QI ) in Florida and Puerto Rico (PR). Methods and Results The population included fee-for-service Medicare beneficiaries age 65+ in Florida and PR , discharged with primary diagnosis of ischemic stroke ( International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], codes 433, 434, 436) in 2010-2013. We used mixed logistic models to assess racial/ethnic differences in outcomes (in-hospital, 30-day, and 1-year mortality, and 30-day readmission) for CR e SD and non- QI hospitals, adjusted for demographic and clinical characteristics. The study included 62 CR e SD hospitals (N=44 013, 84% white, 9% black, 4% Florida Hispanic, 1% PR Hispanic) and 113 non- QI hospitals (N=14 422, 78% white, 7% black, 5% Florida Hispanic, 8% PR Hispanic). For patients treated at CR e SD hospitals, there were no differences in risk-adjusted in-hospital mortality by race/ethnicity; blacks had lower 30-day mortality versus whites (odds ratio, 0.86; 95% confidence interval, 0.77-0.97), but higher 30-day readmission (hazard ratio, 1.09; 1.00-1.18) and 1-year mortality (odds ratio, 1.13; 1.04-1.23); Florida Hispanics had lower 30-day readmission (hazard ratio, 0.87; 0.78-0.98). PR Hispanic and black stroke patients treated at non- QI hospitals had higher risk-adjusted in-hospital, 30-day and 1-year mortality, but similar 30-day readmission versus whites treated in non- QI hospitals. Conclusions Disparities in outcomes were less common in CR e SD than non- QI hospitals, suggesting the benefits of quality improvement programs, particularly those focusing on racial/ethnic disparities.
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Etnicidad , Medicare/economía , Mejoramiento de la Calidad , Grupos Raciales , Sistema de Registros , Accidente Cerebrovascular/etnología , Anciano , Causas de Muerte/tendencias , Planes de Aranceles por Servicios/estadística & datos numéricos , Femenino , Florida/epidemiología , Humanos , Masculino , Puerto Rico/epidemiología , Estudios Retrospectivos , Accidente Cerebrovascular/economía , Tasa de Supervivencia/tendencias , Estados UnidosRESUMEN
This paper aims to analyze the healthcare coordination by Primary Health Care (PHC), with the backdrop of building a Health Care Network (RAS) in a region in the state of São Paulo, Brazil. We conducted a case study with qualitative and quantitative approaches, proceeding to the triangulation of data between the perception of managers and experience of users. We drew analysis realms and variables from the three pillars of healthcare coordination - informational, clinical and administrative/organizational. Stroke was the tracer event chosen and therapeutic itineraries were conducted with users and questionnaires applied to the managers. The central feature of the construction of the Health Care Network in the studied area is the prominence of a philanthropic organization. The results suggest fragility of PHC in healthcare coordination in all analyzed realms. Furthermore, we identified a public-private mix, in addition to services contracted from the Unified Health System (SUS), with out-of-pocket payments for specialist consultation, tests and rehabilitation. Much in the same way that there is no RAS without a robust PHC capable of coordinating care, PHC is unable to play its role without a solid regional arrangement and a virtuous articulation between the three federative levels.
Asunto(s)
Atención a la Salud/organización & administración , Programas Nacionales de Salud/organización & administración , Atención Primaria de Salud/organización & administración , Accidente Cerebrovascular/terapia , Brasil , Atención a la Salud/economía , Gastos en Salud , Humanos , Programas Nacionales de Salud/economía , Atención Primaria de Salud/economía , Accidente Cerebrovascular/economía , Encuestas y CuestionariosRESUMEN
Resumo O objetivo deste artigo é analisar a coordenação do cuidado pela Atenção Primária à Saúde (APS), tendo como pano de fundo o processo de construção da Rede de Atenção à Saúde (RAS) em região do estado de São Paulo. Foi realizado estudo de caso com abordagens quantitativa e qualitativa, procedendo-se à triangulação dos dados, entre a percepção dos gestores e as experiências dos usuários. As dimensões e as variáveis de análise partiram dos três pilares da coordenação do cuidado - informacional, clínico, administrativo/organizacional. Tendo como evento traçador o Acidente Vascular Encefálico, itinerários terapêuticos foram conduzidos com usuários e questionários aplicados a gestores. A construção da Rede de Atenção à Saúde na região estudada tem como traço central o protagonismo de entidade filantrópica. Os resultados sugerem fragilidades da APS em assumir papel de coordenação do cuidado em todas as dimensões analisadas. Ademais, foi identificado mix público-privado para além dos serviços contratados pelo SUS, com desembolso direto para consultas especializadas, exames e reabilitação. Da mesma forma que não existe RAS sem APS robusta capaz de coordenar o cuidado, a APS não consegue exercer seu papel sem um sólido arranjo regional e uma articulação virtuosa entre os três entes federados.
Abstract This paper aims to analyze the healthcare coordination by Primary Health Care (PHC), with the backdrop of building a Health Care Network (RAS) in a region in the state of São Paulo, Brazil. We conducted a case study with qualitative and quantitative approaches, proceeding to the triangulation of data between the perception of managers and experience of users. We drew analysis realms and variables from the three pillars of healthcare coordination - informational, clinical and administrative/organizational. Stroke was the tracer event chosen and therapeutic itineraries were conducted with users and questionnaires applied to the managers. The central feature of the construction of the Health Care Network in the studied area is the prominence of a philanthropic organization. The results suggest fragility of PHC in healthcare coordination in all analyzed realms. Furthermore, we identified a public-private mix, in addition to services contracted from the Unified Health System (SUS), with out-of-pocket payments for specialist consultation, tests and rehabilitation. Much in the same way that there is no RAS without a robust PHC capable of coordinating care, PHC is unable to play its role without a solid regional arrangement and a virtuous articulation between the three federative levels.
Asunto(s)
Humanos , Atención Primaria de Salud/organización & administración , Accidente Cerebrovascular/terapia , Atención a la Salud/organización & administración , Programas Nacionales de Salud/organización & administración , Atención Primaria de Salud/economía , Brasil , Encuestas y Cuestionarios , Gastos en Salud , Accidente Cerebrovascular/economía , Atención a la Salud/economía , Programas Nacionales de Salud/economíaRESUMEN
BACKGROUND: Few studies have assessed regional variation in the organisation of stroke services, particularly health care resourcing, presence of protocols and discharge planning. Our aim was to compare stroke care organisation within middle- (MIC) and high-income country (HIC) hospitals participating in the Head Position in Stroke Trial (HeadPoST). METHODS: HeadPoST is an on-going international multicenter crossover cluster-randomized trial of 'sitting-up' versus 'lying-flat' head positioning in acute stroke. As part of the start-up phase, one stroke care organisation questionnaire was completed at each hospital. The World Bank gross national income per capita criteria were used for classification. RESULTS: 94 hospitals from 9 countries completed the questionnaire, 51 corresponding to MIC and 43 to HIC. Most participating hospitals had a dedicated stroke care unit/ward, with access to diagnostic services and expert stroke physicians, and offering intravenous thrombolysis. There was no difference for the presence of a dedicated multidisciplinary stroke team, although greater access to a broad spectrum of rehabilitation therapists in HIC compared to MIC hospitals was observed. Significantly more patients arrived within a 4-h window of symptoms onset in HIC hospitals (41 vs. 13%; P<0.001), and a significantly higher proportion of acute ischemic stroke patients received intravenous thrombolysis (10 vs. 5%; P=0.002) compared to MIC hospitals. CONCLUSIONS: Although all hospitals provided advanced care for people with stroke, differences were found in stroke care organisation and treatment. Future multilevel analyses aims to determine the influence of specific organisational factors on patient outcomes.
Asunto(s)
Hospitales , Accidente Cerebrovascular/terapia , Isquemia Encefálica/economía , Isquemia Encefálica/epidemiología , Isquemia Encefálica/terapia , Protocolos Clínicos , Estudios Cruzados , Fuerza Laboral en Salud/economía , Capacidad de Camas en Hospitales/economía , Humanos , Alta del Paciente/economía , Posicionamiento del Paciente , Garantía de la Calidad de Atención de Salud/economía , Factores Socioeconómicos , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/epidemiología , Encuestas y Cuestionarios , Terapia Trombolítica/economíaRESUMEN
BACKGROUND: The effect of socioeconomic stressors on the incidence of cardiovascular disease (CVD) is currently open to debate. Using time-series analysis, our study aimed to evaluate the relationship between unemployment rate and hospital admission for acute myocardial infarction (AMI) and stroke in Brazil over a recent 11-year span. METHODS AND RESULTS: Data on monthly hospital admissions for AMI and stroke from March 2002 to December 2013 were extracted from the Brazilian Public Health System Database. The monthly unemployment rate was obtained from the Brazilian Institute for Applied Economic Research, during the same period. The autoregressive integrated moving average (ARIMA) model was used to test the association of temporal series. Statistical significance was set at p<0.05. From March 2002 to December 2013, 778,263 admissions for AMI and 1,581,675 for stroke were recorded. During this time period, the unemployment rate decreased from 12.9% in 2002 to 4.3% in 2013, while admissions due to AMI and stroke increased. However, the adjusted ARIMA model showed a positive association between the unemployment rate and admissions for AMI but not for stroke (estimate coefficient=2.81±0.93; p=0.003 and estimate coefficient=2.40±4.34; p=0.58, respectively). CONCLUSIONS: From 2002 to 2013, hospital admissions for AMI and stroke increased, whereas the unemployment rate decreased. However, the adjusted ARIMA model showed a positive association between unemployment rate and admissions due to AMI but not for stroke. Further studies are warranted to validate our findings and to better explore the mechanisms by which socioeconomic stressors, such as unemployment, might impact on the incidence of CVD.
Asunto(s)
Análisis de Series de Tiempo Interrumpido/tendencias , Infarto del Miocardio/epidemiología , Admisión del Paciente/tendencias , Accidente Cerebrovascular/epidemiología , Desempleo/tendencias , Adulto , Anciano , Brasil/epidemiología , Femenino , Hospitalización/tendencias , Humanos , Análisis de Series de Tiempo Interrumpido/métodos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/economía , Factores Socioeconómicos , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/economíaRESUMEN
BACKGROUND AND PURPOSE: Stroke accounts for more than 10% of all deaths globally and most of it occurs in low- and middle-income countries (LMIC). Income inequality and gross domestic product (GDP) per capita has been associated to stroke mortality in developed countries. In LMIC, GDP per capita is considered to be a more relevant health determinant than income inequality. This study aims to investigate if income inequality is associated to stroke mortality in Brazil at large, but also on regional and state levels, and whether GDP per capita modulates the impact of this association. METHODS: Stroke mortality rates, Gini index and GDP per capita data were pooled for the 2002 to 2009 period from public available databases. Random effects models were fitted, controlling for GDP per capita and other covariates. RESULTS: Income inequality was independently associated to stroke mortality rates, even after controlling for GDP per capita and other covariates. GDP per capita reduced only partially the impact of income inequality on stroke mortality. A decrease in 10 points in the Gini index was associated with 18% decrease in the stroke mortality rate in Brazil. CONCLUSIONS: Income inequality was independently associated to stroke mortality in Brazil.
Asunto(s)
Desarrollo Económico/estadística & datos numéricos , Renta/estadística & datos numéricos , Factores Socioeconómicos , Accidente Cerebrovascular/mortalidad , Brasil/epidemiología , Países en Desarrollo/economía , Producto Interno Bruto/estadística & datos numéricos , Humanos , Modelos Económicos , Análisis de Regresión , Accidente Cerebrovascular/economíaRESUMEN
Advances in tobacco control in Brazil can be reflected in the decrease in prevalence over the past two decades. Death statistics and the occurrence of events and direct costs attributable to tobacco-related diseases have not been frequently estimated in the country. The goal of this article is to estimate the burden of smoking in 2011 regarding mortality, morbidity and medical care costs of the main tobacco-related diseases. A probabilistic microsimulation health economic model was built. The model incorporates the natural history, costs and quality of life of all the tobacco-related adult-specific diseases. Smoking was accountable for 147,072 deaths, 2.69 million years of life lost, 157,126 acute myocardial infarctions, 75,663 strokes, and 63,753 cancer diagnoses. The direct cost for the health system was of BRL 23.37 billion. The monitoring of tobacco-related burden is an important strategy to guide decision-makers and to strenghten health public policies.
Asunto(s)
Costos de la Atención en Salud/estadística & datos numéricos , Fumar/economía , Fumar/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Brasil/epidemiología , Enfermedades Cardiovasculares/inducido químicamente , Enfermedades Cardiovasculares/economía , Enfermedades Cardiovasculares/mortalidad , Costo de Enfermedad , Femenino , Humanos , Incidencia , Esperanza de Vida , Masculino , Persona de Mediana Edad , Morbilidad , Neoplasias/inducido químicamente , Neoplasias/economía , Neoplasias/mortalidad , Prevalencia , Fumar/efectos adversos , Accidente Cerebrovascular/inducido químicamente , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/mortalidadRESUMEN
Os avanços no controle do tabagismo no Brasil podem ser verificados na redução da prevalência nas últimas duas décadas. As estatísticas de óbitos, ocorrência de eventos e custos diretos atribuíveis às doenças tabaco-relacionadas não são estimadas com frequência no país. O objetivo deste artigo foi estimar a carga do tabagismo em 2011, em termos de mortalidade, morbidade e custos da assistência médica das principais doenças tabaco-relacionadas. Desenvolveu-se um modelo econômico baseado em uma microssimulação probabilística de milhares de indivíduos através de coortes hipotéticas que considerou a história natural, os custos diretos em saúde e a qualidade de vida desses indivíduos. O tabagismo foi responsável por 147.072 óbitos, 2,69 milhões anos de vida perdidos, 157.126 infartos agudos do miocárdio, 75.663 acidentes vasculares cerebrais e 63.753 diagnósticos de câncer. O custo para o sistema de saúde foi de R$ 23,37 bilhões. O monitoramento da carga do tabagismo é uma importante estratégica para informar aos tomadores de decisão e fortalecer a política pública de saúde.
Los avances en el control del tabaquismo en Brasil pueden reflejarse en la reducción de la prevalencia observada en las últimas dos décadas. Las estadísticas de muertes, incidencia de eventos y costos directos atribuibles a las enfermedades, relacionadas con el tabaquismo, no han sido estimadas frecuentemente en el país. El objetivo de este estudio fue estimar la carga del tabaquismo en el año 2011, en términos de mortalidad, morbilidad y costos de asistencia médica para las patologías relacionadas con el tabaquismo. Se construyó un modelo de microsimulación probabilístico que incorpora la historia natural, los costos y la calidad de vida de los individuos. En 2011, el tabaquismo fue responsable de 147.072 muertes prematuras, 2,69 millones de años de vida perdidos, 157.126 infartos de miocardio, 75.663 accidentes cerebro-vasculares y 63.753 diagnósticos de cáncer. El costo directo fue de R$ 23,37 mil millones. El monitoreo de la carga de enfermedad atribuible al tabaquismo es una importante estrategia para informar a los responsables de las políticas públicas de salud.
Advances in tobacco control in Brazil can be reflected in the decrease in prevalence over the past two decades. Death statistics and the occurrence of events and direct costs attributable to tobacco-related diseases have not been frequently estimated in the country. The goal of this article is to estimate the burden of smoking in 2011 regarding mortality, morbidity and medical care costs of the main tobacco-related diseases. A probabilistic microsimulation health economic model was built. The model incorporates the natural history, costs and quality of life of all the tobacco-related adult-specific diseases. Smoking was accountable for 147,072 deaths, 2.69 million years of life lost, 157,126 acute myocardial infarctions, 75,663 strokes, and 63,753 cancer diagnoses. The direct cost for the health system was of BRL 23.37 billion. The monitoring of tobacco-related burden is an important strategy to guide decision-makers and to strenghten health public policies.
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Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Costos de la Atención en Salud/estadística & datos numéricos , Fumar/economía , Fumar/mortalidad , Brasil/epidemiología , Costo de Enfermedad , Enfermedades Cardiovasculares/inducido químicamente , Enfermedades Cardiovasculares/economía , Enfermedades Cardiovasculares/mortalidad , Incidencia , Esperanza de Vida , Morbilidad , Neoplasias/inducido químicamente , Neoplasias/economía , Neoplasias/mortalidad , Prevalencia , Fumar/efectos adversos , Accidente Cerebrovascular/inducido químicamente , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/mortalidadAsunto(s)
Costos de la Atención en Salud , Fumar/economía , Accidente Cerebrovascular , Femenino , Humanos , Masculino , México/epidemiología , Fumar/efectos adversos , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/terapia , Atención Terciaria de Salud/economía , Atención Terciaria de Salud/métodosAsunto(s)
Accidente Cerebrovascular/economía , Accidente Cerebrovascular/mortalidad , Anciano , Brasil/epidemiología , Escolaridad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Morbilidad , Valor Predictivo de las Pruebas , Accidente Cerebrovascular/epidemiología , Tasa de Supervivencia/tendencias , Factores de TiempoRESUMEN
OBJECTIVES: In Nicaragua, 30% of current morbidities are associated with tobacco smoking. Tobacco control policy measures have been initiated in this Central American country; however, the population does not have a complete understanding of the long-term consequences of tobacco use. The aim of this study was to compare the direct medical costs of smoking cessation therapies with varenicline, bupropion, nicotine replacement therapy, and unaided cessation in Nicaragua over 5 time horizons: 2, 5, 10, and 20 years, and lifetime. METHODS: The current annual costs of chronic obstructive pulmonary disease, lung cancer, coronary heart disease, and stroke were estimated based on the current annual incidence for each disease using 1 public hospital database (Hospital Lenin Fonseca, 2010). The Benefits of Smoking Cessation on Outcomes simulation model was used to obtain the projected direct costs for each strategy. An adult cohort (N = 3 639 948) from Nicaragua was used and the assessment was conducted using the health care payer's perspective. Costs were discounted at 5% annually. Probabilistic sensitivity analyses were conducted using a Monte Carlo second-order approach. RESULTS: Varenicline is associated with the highest health care cost-savings compared with the other 3 alternatives at 5, 10, and 20 years, and lifetime. At lifetime, varenicline would result in savings of US$4 545 008, US$5 859 300, and US$11 033 221 when compared with bupropion, nicotine replacement therapy, and unaided cessation, respectively. Varenicline also avoided the highest number of smoking-related deaths in comparison with the alternatives. At year 10, varenicline avoided 96, 124, and 234 more deaths than bupropion, nicotine replacement therapy, and unaided cessation, respectively. The results of probabilistic sensitivity analyses support these findings. CONCLUSION: The use of a smoking cessation therapy with varenicline would generate long-term savings to Nicaragua's health care institutions of > US$11 million in the lifetime time horizon.
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Benzazepinas/economía , Bupropión/economía , Inhibidores de Captación de Dopamina/economía , Agonistas Nicotínicos/economía , Quinoxalinas/economía , Cese del Hábito de Fumar/economía , Dispositivos para Dejar de Fumar Tabaco/economía , Adolescente , Adulto , Anciano , Benzazepinas/uso terapéutico , Bupropión/uso terapéutico , Enfermedad Coronaria/economía , Enfermedad Coronaria/etiología , Costos y Análisis de Costo , Inhibidores de Captación de Dopamina/uso terapéutico , Gastos en Salud , Humanos , Neoplasias Pulmonares/economía , Neoplasias Pulmonares/etiología , Persona de Mediana Edad , Nicaragua/epidemiología , Agonistas Nicotínicos/uso terapéutico , Evaluación de Resultado en la Atención de Salud/economía , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Enfermedad Pulmonar Obstructiva Crónica/economía , Enfermedad Pulmonar Obstructiva Crónica/etiología , Quinoxalinas/uso terapéutico , Fumar/efectos adversos , Fumar/mortalidad , Cese del Hábito de Fumar/métodos , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/etiología , Factores de Tiempo , Vareniclina , Adulto JovenRESUMEN
OBJECTIVES: The Oral Rapamycin in ARgentina (ORAR) III trial is a randomized study comparing a strategy of oral rapamycin (OR) plus bare-metal stent (BMS) versus a strategy of drug-eluting stents (DES) in patients with de novo coronary lesions. The purpose of this study was to assess the 3 years cost-effectiveness outcome of each strategy. BACKGROUND: OR after BMS has been associated with reduction of target vessel revascularization (TVR) although its value in long-term efficacy in comparison with DES is unknown. METHODS: In three hospitals in Buenos Aires, Argentina, 200 patients were randomized to OR plus BMS (n = 100) or DES (n = 100). Primary objectives were costs and effectiveness. Cost analysis included in-hospital and follow-up costs. Safety was defined as the composite of death, myocardial infarction (MI), and stroke. Efficacy was defined as TVR. RESULTS: Baseline characteristics between groups were similar. The 3-year follow-up rate was 99%. Cardiac mortality was 2% and 5% in OR group and DES group, respectively (P = 0.44). The composite of death, MI and stroke rate was 11% in OR group and 20% in DES group (P = 0.078). TVR rate was 14.5% in OR group and 17.6% in DES group (P = 0.50), respectively. Three year cumulative costs were significantly lower in the OR arm as compared to the DES arm (P = 0.0001) and DES strategy did not result cost-effective according to the non-inferiority test. CONCLUSIONS: At 3 years follow-up, there were no differences in effectiveness between the two strategies, and DES strategy was not more cost-effective as compared to OR plus BMS.
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Fármacos Cardiovasculares/administración & dosificación , Fármacos Cardiovasculares/economía , Enfermedad de la Arteria Coronaria/terapia , Stents Liberadores de Fármacos/economía , Costos de la Atención en Salud , Metales/economía , Intervención Coronaria Percutánea/economía , Sirolimus/administración & dosificación , Sirolimus/economía , Stents/economía , Administración Oral , Anciano , Argentina , Distribución de Chi-Cuadrado , Terapia Combinada , Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Enfermedad de la Arteria Coronaria/economía , Reestenosis Coronaria/economía , Reestenosis Coronaria/etiología , Ahorro de Costo , Análisis Costo-Beneficio , Costos de los Medicamentos , Femenino , Costos de Hospital , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/economía , Infarto del Miocardio/etiología , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/mortalidad , Modelos de Riesgos Proporcionales , Diseño de Prótesis , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: Differences in definitions of socioeconomic status and between study designs hinder their comparability across countries. We aimed to analyze the correlation between 3 widely used macrosocioeconomic status indicators and clinical outcomes. METHODS: We selected population-based studies reporting incident stroke risk and/or 30-day case-fatality according to prespecified criteria. We used 3 macrosocioeconomic status indicators that are consistently defined by international agencies: per capita gross domestic product adjusted for purchasing power parity, total health expenditures per capita at purchasing power parity, and unemployment rate. We examined the correlation of each macrosocioeconomic status indicator with incident risk of stroke, 30-day case-fatality, proportion of hemorrhagic strokes, and age at stroke onset. RESULTS: Twenty-three articles comprising 30 population-based studies fulfilled the eligibility criteria. Age-adjusted incident risk of stroke using the standardized World Health Organization World population was associated to lower per capita gross domestic product adjusted for purchasing power parity (ρ=-0.661, P=0.027, R(2)=0.32) and total health expenditures per capita at purchasing power parity (ρ=-0.623, P=0.040, R(2)=0.26). Thirty-day case-fatality rates and proportion of hemorrhagic strokes were also related to lower per capita gross domestic product adjusted for purchasing power parity and total health expenditures per capita at purchasing power parity. Moreover, stroke occurred at a younger age in populations with low per capita gross domestic product adjusted for purchasing power parity and total health expenditures per capita at purchasing power parity. There was no correlation between unemployment rates and outcome measures. CONCLUSIONS: Lower per capita gross domestic product adjusted for purchasing power parity and total health expenditures per capita at purchasing power parity were associated with higher incident risk of stroke, higher case-fatality, a greater proportion of hemorrhagic strokes, and lower age at stroke onset. As a result, these macrosocioeconomic status indicators may be used as proxy measures of quality of primary prevention and acute care and considered as important factors for developing strategies aimed at improving worldwide stroke care.
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Producto Interno Bruto , Gastos en Salud , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/epidemiología , Edad de Inicio , Humanos , Incidencia , Clase Social , Accidente Cerebrovascular/mortalidad , Tasa de Supervivencia , Organización Mundial de la SaludRESUMEN
BACKGROUND: The association between physical activity and quality of life in stroke survivors has not been analyzed within a framework related to the human development index. This study aimed to identify differences in physical activity level and in the quality of life of stroke survivors in two cities differing in economic aspects of the human development index. METHODS: Two groups of subjects who had suffered a stroke at least a year prior to testing and showed hemiplegia or hemiparesis were studied: a group from Belo Horizonte (BH) with 48 people (51.5 ± 8.7 years) and one from Montes Claros (MC) with 29 subjects (55.4 ± 8.1 years). Subsequently, regardless of location, the groups were divided into Active and Insufficiently Active so their difference in terms of quality of life could be analyzed. RESULTS: There were no significant differences between BH and MCG when it came to four dimensions of physical health that were evaluated (physical functioning, physical aspect, pain and health status) or in the following four dimensions of mental health status (vitality, social aspect, emotional aspect and mental health). However, significantly higher mean values were found in Active when compared with Insufficiently Active individuals in various measures of physical health (physical functioning 56.2 ± 4.4 vs. 47.4 ± 6.9; physical aspect 66.5 ± 6.5 vs. 59.1 ± 6.7; pain 55.9 ± 6.2 vs. 47.7 ± 6.0; health status 67.2 ± 4.2 vs. 56.6 ± 7.8) (arbitrary units), and mental health (vitality 60.9 ± 6.8 vs. 54.1 ± 7.2; social aspect 60.4 ± 7.1 vs. 54.2 ± 7.4; emotional aspect 64.0 ± 5.5 vs. 58.1 ± 6.9; mental health status 66.2 ± 5.5 vs. 58.4 ± 7.5) (arbitrary units). CONCLUSIONS: Despite the difference between the cities concerning HDI values, no significant differences in quality of life were found between BH and MCG. However, the Active group showed significantly better results, confirming the importance of active lifestyle to enhance quality of life in stroke survivors.