RESUMO
The aim was to analyse the implementation dynamics of the essential medicines list (EML). We used the government expenditures on medicines and Brazil as a case study. Drug purchases were considered as a proxy for utilization. The essential medicines (EMs) expenditures were followed over time by Brazilian National EMLs life-time and defined by broad therapeutic categories and by specific medicines. Brazil increased the number of the medicines during the last four editions of Brazilian National EMLs and the federal government expenditures on them. The EML implementation dynamics changed the distribution of expenditures on EMs. We identified a common set of 404 EMs present in all four editions of the Brazilian National EMLs. There was a proportional decrease in expenditures on anti-infectives for systemic use, blood and blood-forming organs and alimentary tract and metabolism, and increase in expenditures on antineoplastic and immunomodulating agents. The expenditures distribution per specific medicines revealed that a small set of EMs was responsible for 50% or more of expenditures considering Brazilian National EML life-time for all four periods. The increase in expenditures on EMs in Brazil was a consequence of the newer medicines incorporated over time in the Brazilian National EMLs. The use of the medicines expenditures as a source of data and the definition of an EML life-time permitted follow-up of the implementation dynamics of different versions of the Brazilian National EMLs. Our results have implications for policymakers and stakeholders to gain a better understanding of the role EMLs play in health system sustainability and in the provision of the most beneficial heath care.
Assuntos
Custos de Medicamentos , Uso de Medicamentos , Medicamentos Essenciais/uso terapêutico , Formulários Farmacêuticos como Assunto , Brasil , Bases de Dados Factuais , Custos de Medicamentos/tendências , Uso de Medicamentos/tendências , Medicamentos Essenciais/economia , Governo Federal , Gastos em Saúde , Implementação de Plano de Saúde , Humanos , Estudos de Casos OrganizacionaisRESUMO
OBJECTIVES: To assess whether ad libitum consumption of thiamin-fortified fish sauce over 6 months yields higher erythrocyte thiamin diphosphate concentrations (eTDP) among women of childbearing age and their children aged 12-59 months compared with control sauce containing no thiamin. STUDY DESIGN: In this double-blind, randomized controlled efficacy trial, 276 nonpregnant, nonlactating women (18-45 years of age) and their families in Prey Veng, Cambodia, were randomized to receive 1 of 3 fish sauce formulations: low thiamin concentration (low, 2 g/L), high thiamin concentration (high, 8 g/L), or a control (no thiamin) fish sauce. Baseline (t = 0) and endline (t = 6 months) eTDP were measured with the use of high-performance liquid chromatography with a fluorescence detector. RESULTS: Fish sauce consumption did not differ between treatment groups (P = .19). In intent-to-treat analysis, women's baseline-adjusted endline eTDP (mean; 95% CI) was higher among women in the low (259; 245-274 nmol/L) and high (257; 237-276 nmol/L) groups compared with control (184; 169-198 nmol/L; P < .001); low and high groups did not differ (P = .83). Similarly, children's baseline-adjusted eTDP was higher in the low (259; 246-271 nmol/L) and high (257; 243-270 nmol/L) groups compared with control (213; 202-224 nmol/L; P < .001). CONCLUSION: Fortified fish sauce appears to be an efficacious means of improving biochemical thiamin status in nonpregnant, nonlactating women and their children (1-5 years of age) living in rural Cambodia. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02221063.
Assuntos
Eritrócitos/metabolismo , Produtos Pesqueiros , Alimentos Fortificados , Tiamina/administração & dosagem , Adolescente , Adulto , Animais , Camboja , Criança , Pré-Escolar , Cromatografia Líquida , Método Duplo-Cego , Feminino , Humanos , Lactente , Pessoa de Meia-Idade , Estado Nutricional , População Rural , Tiamina/sangue , Adulto JovemRESUMO
OBJECTIVE: To explore which attributes of insulin therapy drive patients' preferences for management in Canada and Brazil. METHODS: A qualitative design was implemented in which a total of 32 patients with type 2 diabetes from Canada and Brazil, were interviewed in one of the 4 focus groups, or 16 individual interviews. Eighteen participants (56%) were women and fourteen participants (44%) were men (15 insulin nonusers and 17 insulin users). Two focus groups of 4 participants each and 9 individual interviews were conducted in Brazil. In Canada, 2 focus groups of 4 participants each and 7 individual interviews were conducted. A framework analysis was used to analyse all data. RESULTS: Brazilian participants, when considering two insulin treatments, would prefer the one that had fewer side-effects (specially hypoglycemia events), was noninjectable, had the lowest cost and was most effective. Meanwhile, Canadian participants would prefer a treatment that had fewer side-effects (specially weight gain), was less invasive, was more convenient and was most effective. CONCLUSIONS: Finding the insulin-delivery system and the attributes of insulin therapy that best meet patients' preferences may lead to improved control, through improved compliance, which may ultimately reduce the financial burden of the disease and improve quality of life.
RESUMO
CONTEXT: Visceral leishmaniasis (VL) is a severe and potentially fatal infection caused by the trypanosome parasite Leishmania sp. Over 90% of reported cases occur in India, Bangladesh, Nepal, Sudan, and Brazil, affecting mainly impoverished individuals and creating a significant economic burden through direct and indirect costs of treatment. OBJECTIVES: To identify the direct and indirect costs of VL treatment, compare these costs to household income, and identify the barriers to treatment in each of the five VL-endemic countries. METHODS: Articles obtained through PubMed (US National Library of Medicine), EMBASE, and Cochrane Library were selected for relevance to VL treatment, costs for all forms of amphotericin B, miltefosine, paromomycin, and antimony compounds, and healthcare costs in India, Bangladesh, Nepal, Brazil, and Sudan. Healthcare statistics were obtained from the World Health Organization Statistical Information System, Médecins Sans Frontieres, and each country's national health ministry. RESULTS: Per capita GDP, per capita GNI, cost of drugs, and hospitalization expenses differ by up to 10-fold in each of the five countries where VL is hyperendemic, resulting in unequal barriers to treatment. We found that the cost of specific drugs influences the choice of therapy. CONCLUSIONS: Poverty and VL treatment-related costs cause potential limitations in the provision of full and efficacious treatment, which may result in further dissemination of the disease. Effective nonparenteral antileishmania drugs would provide a significant advantage in reducing the barriers to VL treatment.
Assuntos
Antiprotozoários/uso terapêutico , Efeitos Psicossociais da Doença , Leishmaniose Visceral/tratamento farmacológico , Animais , Antiprotozoários/economia , Surtos de Doenças , Custos de Medicamentos , Doenças Endêmicas , Custos Hospitalares , Humanos , Leishmaniose Visceral/economia , Leishmaniose Visceral/epidemiologia , Áreas de PobrezaRESUMO
OBJECTIVE: To evaluate patients' preferences for various attributes of insulin treatment, including route of insulin delivery. METHODS: We used a discrete choice experiment (DCE) to quantify patients' preferences. The attributes (and levels) included in the DCE questionnaire were: glucose control, frequency of hypoglycemic events, weight gain, route of administration for the long-acting and the short-acting insulin, and out-of-pocket cost. Data were analyzed using conditional logit regression and segmented models were also developed to evaluate differences in preferences between subgroups. RESULTS: Two hundred and seventy-four questionnaires were completed. The mean age (SD) of participants was 56.7 (12.9) years. Forty-nine percent of participants were insulin users, and 17% had type 1 diabetes. Overall, patients' ideal insulin treatment would provide better glucose control, result in fewer adverse reactions, have the lowest cost, and be administered orally. Overall, there was a strong positive preference for better glucose control relative to the other attributes. Segmented analyses by insulin use and type of diabetes suggest that there may be an important psychosocial barrier to initiating insulin therapy but that patients tend to adjust to subcutaneous administration once they initiate therapy. CONCLUSIONS: This study illustrates the importance that patients with diabetes place on glucose control and how preferences for insulin therapy differ between subgroups. Specifically, efforts need to be made to overcome the psychosocial barriers to initiating insulin therapy which may lead to improved control through improved treatment acceptance and ultimately improve patients' quality of life and reduce the economic burden of the disease.
RESUMO
BACKGROUND: An evaluation of patients' preferences is necessary to understand the demand for different insulin delivery systems. The aim of this study was to investigate the association between socioeconomic status (SES) and patients' preferences and willingness to pay (WTP) for various attributes of insulin administration for diabetes management. METHODS: We conducted a discrete choice experiment (DCE) to determine patients; preferences and their WTP for hypothetical insulin treatments. Both self-reported annual household income and education completed were used to explore differences in treatment preferences and WTP for different attributes of treatment across different levels of SES. RESULTS: The DCE questionnaire was successfully completed by 274 patients. Overall, glucose control was the most valued attribute by all socioeconomic groups, while route of insulin delivery was not as important. Patients with higher incomes were willing to pay significantly more for better glucose control and to avoid adverse events compared to lower income groups. In addition, they were willing to pay more for an oral short-acting insulin ($Can 71.65 [95% confidence interval, $40.68, $102.62]) compared to the low income group ($Can 9.85 [95% confidence interval, 14.86, 34.56; P < 0.01]). Conversely, there were no differences in preferences when the sample was stratified by level of education. CONCLUSIONS: This study revealed that preferences and WTP for insulin therapy are influenced by income but not by level of education. Specifically, the higher the income, the greater desire for an oral insulin delivery system, whereas an inhaled route becomes less important for patients.
Assuntos
Diabetes Mellitus/tratamento farmacológico , Insulina/administração & dosagem , Preferência do Paciente/psicologia , Administração por Inalação , Administração Oral , Adulto , Idoso , Glicemia , Colúmbia Britânica , Comportamento de Escolha , Intervalos de Confiança , Diabetes Mellitus/economia , Escolaridade , Feminino , Homeostase , Humanos , Insulina/efeitos adversos , Insulina/economia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Preferência do Paciente/economia , Medição de Risco , Fatores Socioeconômicos , Inquéritos e QuestionáriosRESUMO
OBJECTIVES: The aim of this study was to determine the insulin-delivery system and the attributes of insulin therapy that best meet patients' preferences, and to estimate patients' willingness-to-pay (WTP) for them. METHODS: This was a cross-sectional discrete choice experiment (DCE) study involving 378 Canadian patients with type 1 or type 2 diabetes. Patients were asked to choose between two hypothetical insulin treatment options made up of different combinations of the attribute levels. Regression coefficients derived using conditional logit models were used to calculate patients' WTP. Stratification of the sample was performed to evaluate WTP by predefined subgroups. RESULTS: A total of 274 patients successfully completed the survey. Overall, patients were willing to pay the most for better blood glucose control followed by weight gain. Surprisingly, route of insulin administration was the least important attribute overall. Segmented models indicated that insulin naïve diabetics were willing to pay significantly more for both oral and inhaled short-acting insulin compared with insulin users. Surprisingly, type 1 diabetics were willing to pay $C11.53 for subcutaneous short-acting insulin, while type 2 diabetics were willing to pay $C47.23 to avoid subcutaneous short-acting insulin (p < .05). These findings support the hypothesis of a psychological barrier to initiating insulin therapy, but once that this barrier has been overcome, they accommodate and accept injectable therapy as a treatment option. CONCLUSIONS: By understanding and addressing patients' preferences for insulin therapy, diabetes educators can use this information to find an optimal treatment approach for each individual patient, which may ultimately lead to improved control, through improved compliance, and better diabetes outcomes.