Health-related quality of life associated with diabetic retinopathy in patients at a public primary care service in southern Brazil.

OBJECTIVE: This study aimed to establish the utility values of different health states associated with diabetic retinopathy in a Brazilian sample to provide input to model-based economic evaluations. METHODS: This cross-sectional study was performed in a sample of patients with type 2 diabetes mellitus (T2D) who underwent teleophthalmology screening at a primary care service from 2014 to 2016. Five diabetic retinopathy health states were defined: absent, non-sight-threatening, sight-threatening, and bilateral blindness. Utility values were estimated using the Brazilian EuroQol five dimensions (EQ-5D) tariffs. Descriptive statistics were calculated. Analysis of covariance was performed to adjust the utility values for potential confounders. RESULTS: The study included 206 patients. The mean (± standard deviation [SD]) utility value was 0.765 ± 0.19 (95% confidence interval [CI], 0.740-0.790). The adjusted mean utility value was 0.748 (95% CI, 0.698-0.798) in patients without diabetic retinopathy, 0.752 (95% CI, 0.679-0.825) in those with non-sight-threatening state, 0.628 (95% CI, 0.521-0.736) in those with sight-threatening state, and 0.355 (95% CI, 0.105-0.606) in those with bilateral blindness. A significant utility decrement was found between patients without diabetic retinopathy and those with a sight-threatening health state (0.748 vs. 0.628, respectively, p = 0.04). CONCLUSION: The findings suggest that a later diabetic retinopathy health state is associated with a decrement in utility value compared with the absence of retinopathy in patients with T2D. The results may be useful as preliminary input to model-based economic evaluations. Further research is needed to investigate the impact of diabetic retinopathy on health-related quality of life in a sample more representative of the Brazilian population.

Health-related quality of life associated with diabetic retinopathy in patients at a public primary care service in southern Brazil

ABSTRACT Objective This study aimed to establish the utility values of different health states associated with diabetic retinopathy in a Brazilian sample to provide input to model-based economic evaluations. Subjects and methods This cross-sectional study was performed in a sample of patients with type 2 diabetes mellitus (T2D) who underwent teleophthalmology screening at a primary care service from 2014 to 2016. Five diabetic retinopathy health states were defined: absent, non-sight-threatening, sight-threatening, and bilateral blindness. Utility values were estimated using the Brazilian EuroQol five dimensions (EQ-5D) tariffs. Descriptive statistics were calculated. Analysis of covariance was performed to adjust the utility values for potential confounders. Results The study included 206 patients. The mean (± standard deviation [SD]) utility value was 0.765 ± 0.19 (95% confidence interval [CI], 0.740-0.790). The adjusted mean utility value was 0.748 (95% CI, 0.698-0.798) in patients without diabetic retinopathy, 0.752 (95% CI, 0.679-0.825) in those with non-sight-threatening state, 0.628 (95% CI, 0.521-0.736) in those with sight-threatening state, and 0.355 (95% CI, 0.105-0.606) in those with bilateral blindness. A significant utility decrement was found between patients without diabetic retinopathy and those with a sight-threatening health state (0.748 vs. 0.628, respectively, p = 0.04). Conclusions The findings suggest that a later diabetic retinopathy health state is associated with a decrement in utility value compared with the absence of retinopathy in patients with T2D. The results may be useful as preliminary input to model-based economic evaluations. Further research is needed to investigate the impact of diabetic retinopathy on health-related quality of life in a sample more representative of the Brazilian population.

Osteopathic manipulative treatment combined with exercise improves pain and disability in individuals with non-specific chronic neck pain: A pragmatic randomized controlled trial.

PURPOSE: To determine effectiveness of osteopathic manipulative treatment combined with stretching and strengthening exercises in the cervical region on pain and disability in individuals with non-specific chronic neck pain. METHODS: 90 adults with non-specific chronic neck pain were randomized to either exercises group (EG, n = 45) or osteopathic manipulative treatment associated with exercises group (OMT/EG, n = 45). The primary outcomes were obtained by the use of Numeric Pain-Rating Scale (NPRS), Pressure Pain Threshold (PPT) and Neck Disability Index (NDI). Secondary outcomes included range of motion (ROM) for cervical spine rotation, Fear-Avoidance Beliefs Questionnaire Work/Physical Activity (FABQ-W/PA) and Pain-self efficacy at two different moments: baseline and 4 weeks after the first treatment. Techniques and dosages of OMT were selected pragmatically by a registered osteopath. Generalized Estimating Equations model (GEE), complemented by the Least Significant Difference (LSD) and the intention-to-treat analysis, was used to assess the clinical outcomes. RESULTS: Analysis with GEE indicated that OMT/EG reduced pain and disability more than the EG alone after 4 weeks of treatment with statistically significant difference (p < 0,05), as well as cervical active rotation was significantly improved (p = 0.03). There were no between-group differences observed in Pressure Pain Threshold (PPT) measure, Fear-Avoidance Beliefs Questionnaire and Pain-self efficacy. CONCLUSION: The association between OMT and exercises reduces pain and improves functional disability more than only exercise for individuals with non-specific chronic neck pain.

Cost-utility Analysis of Opportunistic and Systematic Diabetic Retinopathy Screening Strategies from the Perspective of the Brazilian Public Healthcare System.

OBJECTIVE: To perform a cost-utility analysis of diabetic retinopathy (DR) screening strategies from the perspective of the Brazilian Public Healthcare System. METHODS: A model-based economic evaluation was performed to estimate the incremental costs per quality-adjusted life-year (QALY) gained between three DR screening strategies: (1) the opportunistic ophthalmology referral-based (usual practice), (2) the systematic ophthalmology referral-based, and (3) the systematic teleophthalmology-based. The target population included individuals with type 2 diabetes (T2D) aged 40 years, without retinopathy, followed over a 40-year time horizon. A Markov model was developed with five health states and a 1-year cycle. Model parameters were based on literature and country databases. One-way and probabilistic sensitivity analyses were performed to assess model parameters' uncertainty. WHO willingness-to-pay (WHO-WTP) thresholds were used as reference (i.e. one and three times the Brazilian per capita Gross Domestic Product of R$32747 in 2018). RESULTS: Compared to usual practice, the systematic teleophthalmology-based screening was associated with an incremental cost of R$21445/QALY gained ($9792/QALY gained). The systematic ophthalmology referral-based screening was more expensive (incremental costs = R$4) and less effective (incremental QALY = -0.012) compared to the systematic teleophthalmology-based screening. The probability of systematic teleophthalmology-based screening being cost-effective compared to usual practice was 0.46 and 0.67 at the minimum and the maximum WHO-WTP thresholds, respectively. CONCLUSION: Systematic teleophthalmology-based DR screening for the Brazilian population with T2D would be considered very cost effective compared to the opportunistic ophthalmology referral-based screening according to the WHO-WTP threshold. However, there is still a considerable amount of uncertainty around the results.

Diagnostic performance of retinal digital photography for diabetic retinopathy screening in primary care.

Introduction: We must study alternatives to structure an effective diabetic retinopathy screening program for Brazilian public health system. Objectives: Evaluate the diagnostic performance of retinal digital photography for diabetic retinopathy screening in primary care, accuracy of the family physician in diabetic retinopathy identification compared to the ophthalmologist, and the need for dilation. Methodology: In a primary care service were performed retinal photographs with non-mydriatic Retinal Camera in 219 type 2 diabetic patients with and without medication mydriasis. We evaluated the performance of the diagnostic of the photos graded by three family physicians with training compared to two ophthalmologists (gold standard), and explore related factors with the need for mydriasis pharmacologically. Results: The prevalence of diabetic retinopathy and proliferative diabetic retinopathy was 19.2% and 1.5%, respectively. The sensitivity of family physicians to evaluate diabetic retinopathy averaged 82.9% (66.7-94.8%); specificity, 92% (90.2-93.3%); the accuracy, 90.3% (88.2-93%) and positive predictive value, 71.2% (68-75.5%). The agreement calculated using the kappa adjusted coefficient was from 0.74 to 0.8 for retinopathy and 0.88 to 0.92 for macular edema. Without drug mydriasis the photos were unreadable by 14.8%, when using mydriatic collyrium this number decreased to 8.7% (McNemar test, P < 0.005). Patients with more than 65 years old has more readability after drug mydriasis (McNemar test, P = 0.011). Conclusion: Trained family physician reached a good performance for evaluation of retinography for diabetic retinopathy. There was improvement in readability with pupil dilation in older patients.

Tratamento restaurador atraumático (Estudo da sua aplicabilidade em escolares de Tangará/SC) / Atraumatic restorative treatment (study about its indication in students from Tangará/SC)

O tratamento restaurador atraumatico, conhecido pela sigla do inglês ART, envolve restaurações atraumáticas e procedimentos educativos-preventivos. É uma formasimplificada de atendimento, que consiste na remoção do tecido cariado com instrumentação manual. Dispensao uso de anestesia e isolamento absoluto, permitindo sua aplicação em locais desprovidos de equipamentos odontológicos. Os estudos publicados sobre o ART abordaram principalmente aspectos relativos à longevidade dessas restaurações e pouco ou nada foi publicado sobre a sua real aplicabilidade ou indicações em relaçãoaos procedimentos convencionais, objetivo do presenteestudo. Foram examinados 348 escolares (6 a 13 anos), estudantes de Tangará-SC. Entre eles, 80,75 porcento apresentavam necessidade de tratamento odontológico invasivo, sendo que 39,94 porcento poderiam ser tratados com o ART e 68,39 porcento precisavam de intervenção convencional. Conclui-se que os escolares examinados apresentavem necessidade acumulada de tratamento odontológico. O tratamento restaurador atraumático apresentou maior indicação para os dentes deciduos que para os permanentes