Unveiling the truth: is COVID-19 reimbursement in Colombia a flawed design? A cost-of-illness analysis for moderate, severe and critical infections.

PURPOSE: This study examines the financial impact of the COVID-19 pandemic on the Colombian Health System, focusing on the adequacy of reimbursement rates for inpatient stays. The study, based on a cost of illness analysis, aims to evaluate the effectiveness of the reimbursement scheme and identify potential economic losses within the health system. PATIENTS AND METHODS: The study protocol outlines the inclusion criteria for patients >18 years with confirmed COVID-19 infection and moderate to critical disease. Patients hospitalised between June 2020 and June 2021 for at least 24 hours were included. Exclusion criteria involved pregnant patients and those initially hospitalised for non-COVID-19. RESULTS: The study included 781 patients contributing to 790 hospitalisations. Demographic and clinical characteristics were analysed, with critical illness being the most prevalent category (61%). The overall mortality rate was 20.3%, primarily observed in critically ill patients. In the general ward for moderate cases, the reimbursement rate saw a substantial increase from US$3237 in 2020 to US$6760 in 2021, surpassing median resource utilisation. However, for severe cases in the intermediate care unit, reimbursement rates decreased, indicating potential insufficiency in covering costs. In the intensive care unit for critical cases, despite improved reimbursement rates, median resource utilisation still exceeds the 2021 rate, suggesting financial insufficiency in reimbursement rates. CONCLUSION: Our study underscores the inadequacies of the previous reimbursement system in addressing the varying resource utilisation and costs associated with COVID-19 inpatient care. Our analysis reveals substantial discrepancies between estimated costs and actual resource utilisation, particularly for severe and critical cases. We advocate for government flexibility in revising reimbursement baskets, supported by pilot studies to assess effectiveness. The use of real-world evidence forms a crucial basis for informed adjustments to reimbursement levels in preparation for future pandemics. This proactive approach ensures alignment between reimbursement policies and the actual costs associated.

Managed competition in Colombia: convergence of public and private insurance and delivery.

The Colombian health system has made a deep transition into managed competition since a major reform in 1993. A market for insurers was created, the consumer has free choice of insurer and a national-level equalisation fund distributes revenues via a per-capita payment. Fully subsidised insurance for the poor and informal, and a comprehensive standardised benefit package for subsidised and contributory schemes (both schemes covering 98 per cent of the population), has led to a low level of out-of-pocket expenses and high financial protection, as well as to reduced gaps in equity in access. The preconditions for managed competition are largely met, but improving health care providers' organisation towards integrated care, to enable them to deliver more value, is a necessary step to achieve the expected results of managed competition in terms of efficiency and quality. Although the current system is likely to be reformed in the coming months, the nature and extent of those reforms are not defined yet, so our analysis is based on the current system.

Cost Analysis of High-Flow Oxygen Therapy Compared with Conventional Oxygen Therapy in Severe COVID-19 in Colombia: Data from a Randomized Clinical Trial.

Background: A randomized clinical trial (HiFlo-COVID-19 Trial) showed that among patients with severe COVID-19, treatment with high-flow oxygen therapy (HFOT) significantly reduced the need for invasive mechanical ventilation support and time for clinical recovery compared with conventional oxygen therapy (COT). However, the cost of this strategy is unknown. Objective: We examined total cost of HFOT treatment compared with COT in real-world setting. Methods: We conducted a post-trial-based cost analysis from the perspective of a managed competition healthcare system, using actual records of billed costs. Cost categories include general ward, intensive care unit, procedures, imaging, laboratories, medications, supplies, and others. Results: A total of 188 participants (mean age 60, 33% female) were included. Average costs (and standard deviation) in the HFOT group were USD $7992 (7394) and in the COT group USD $ 10,190 (9402). Differences, however, did not reach statistical significance (P=0.093). However, resource use was always less costly for the HNFO group, with an overall percentage decrease of 27%. Two categories make up 72% of all savings: medications (41%) and intensive care unit (31%). Conclusion: For patients in ICU with severe COVID-19 the cost of treatment with HFOT as compared to COT is likely to be cost-saving due to less use of medications and length of stay in ICU.

Automated extraction of information from free text of Spanish oncology pathology reports.

Background: Pathology reports are stored as unstructured, ungrammatical, fragmented, and abbreviated free text with linguistic variability among pathologists. For this reason, tumor information extraction requires a significant human effort. Recording data in an efficient and high-quality format is essential in implementing and establishing a hospital-based-cancer registry. Objective: This study aimed to describe implementing a natural language processing algorithm for oncology pathology reports. Methods: An algorithm was developed to process oncology pathology reports in Spanish to extract 20 medical descriptors. The approach is based on the successive coincidence of regular expressions. Results: The validation was performed with 140 pathological reports. The topography identification was performed manually by humans and the algorithm in all reports. The human identified morphology in 138 reports and by the algorithm in 137. The average fuzzy matching score was 68.3 for Topography and 89.5 for Morphology. Conclusions: A preliminary algorithm validation against human extraction was performed over a small set of reports with satisfactory results. This shows that a regular-expression approach can accurately and precisely extract multiple specimen attributes from free-text Spanish pathology reports. Additionally, we developed a website to facilitate collaborative validation at a larger scale which may be helpful for future research on the subject.

Introducción: Los reportes de patología están almacenados como texto libre sin estructura, gramática, fragmentados o abreviados, con variabilidad lingüística entre patólogos. Por esta razón, la extracción de información de tumores requiere un esfuerzo humano significativo. Almacenar información en un formato eficiente y de alta calidad es esencial para implementar y establecer un registro hospitalario de cáncer. Objetivo: Este estudio busca describir la implementación de un algoritmo de Procesamiento de Lenguaje Natural para reportes de patología oncológica. Métodos: Desarrollamos un algoritmo para procesar reportes de patología oncológica en Español, con el objetivo de extraer 20 descriptores médicos. El abordaje se basa en la coincidencia sucesiva de expresiones regulares. Resultados: La validación se hizo con 140 reportes de patología. La identificación topográfica se realizó por humanos y por el algoritmo en todos los reportes. La morfología fue identificada por humanos en 138 reportes y por el algoritmo en 137. El valor de coincidencias parciales (fuzzy matches) promedio fue de 68.3 para Topografía y 89.5 para Morfología. Conclusiones: Se hizo una validación preliminar del algoritmo contra extracción humana sobre un pequeño grupo de reportes, con resultados satisfactorios. Esto muestra que múltiples atributos del espécimen pueden ser extraídos de manera precisa de texto libre de reportes de patología en Español, usando un abordaje de expresiones regulares. Adicionalmente, desarrollamos una página web para facilitar la validación colaborativa a gran escala, lo que puede ser beneficioso para futuras investigaciones en el tema.

Scarcity in abundance? Spatial inequalities in Rheumatoid Arthritis in a health system with financial equity.

BACKGROUND: This paper estimates spatial inequalities of Rheumatoid Arthritis (RA) in Colombia and explores correlates of those disparities from a health system perspective. METHODS: We apply descriptive epidemiology to healthcare administrative records for estimation of crude and age-standardized prevalences, and health systems thinking for identification of barriers to effective access in RA diagnosis. RESULTS: The crude and age-standardized RA prevalence for Colombia in 2018 is estimated at 0.43% and 0.36%, respectively. In the contributory regime, the binding constraint is effective access to rheumatologists in rural and sparsely populated areas; this constraint in workforce affects service delivery, and ultimately comes from the lack of a differentiated model for effective provision of healthcare in those areas (governance). CONCLUSIONS: There are opportunities for implementation of public health policies and health system interventions that would lead to a better identification of RA patients and the subsequent more precise estimation of RA prevalence, and most importantly, to reduce exposition to risk factors and accurate diagnosis and treatment of RA patients.

Automated extraction of information from free text of Spanish oncology pathology reports

Background: Pathology reports are stored as unstructured, ungrammatical, fragmented, and abbreviated free text with linguistic variability among pathologists. For this reason, tumor information extraction requires a significant human effort. Recording data in an efficient and high-quality format is essential in implementing and establishing a hospital-based-cancer registry Objective: This study aimed to describe implementing a natural language processing algorithm for oncology pathology reports. Methods: An algorithm was developed to process oncology pathology reports in Spanish to extract 20 medical descriptors. The approach is based on the successive coincidence of regular expressions. Results: The validation was performed with 140 pathological reports. The topography identification was performed manually by humans and the algorithm in all reports. The human identified morphology in 138 reports and by the algorithm in 137. The average fuzzy matching score was 68.3 for Topography and 89.5 for Morphology. Conclusions: A preliminary algorithm validation against human extraction was performed over a small set of reports with satisfactory results. This shows that a regular-expression approach can accurately and precisely extract multiple specimen attributes from free-text Spanish pathology reports. Additionally, we developed a website to facilitate collaborative validation at a larger scale which may be helpful for future research on the subject.

Introducción: Los reportes de patología están almacenados como texto libre sin estructura, gramática, fragmentados o abreviados, con variabilidad lingüística entre patólogos. Por esta razón, la extracción de información de tumores requiere un esfuerzo humano significativo. Almacenar información en un formato eficiente y de alta calidad es esencial para implementar y establecer un registro hospitalario de cáncer. Objetivo: Este estudio busca describir la implementación de un algoritmo de Procesamiento de Lenguaje Natural para reportes de patología oncológica. Métodos: Desarrollamos un algoritmo para procesar reportes de patología oncológica en Español, con el objetivo de extraer 20 descriptores médicos. El abordaje se basa en la coincidencia sucesiva de expresiones regulares. Resultados: La validación se hizo con 140 reportes de patología. La identificación topográfica se realizó por humanos y por el algoritmo en todos los reportes. La morfología fue identificada por humanos en 138 reportes y por el algoritmo en 137. El valor de coincidencias parciales (fuzzy matches) promedio fue de 68.3 para Topografía y 89.5 para Morfología. Conclusiones: Se hizo una validación preliminar del algoritmo contra extracción humana sobre un pequeño grupo de reportes, con resultados satisfactorios. Esto muestra que múltiples atributos del espécimen pueden ser extraídos de manera precisa de texto libre de reportes de patología en Español, usando un abordaje de expresiones regulares. Adicionalmente, desarrollamos una página web para facilitar la validación colaborativa a gran escala, lo que puede ser beneficioso para futuras investigaciones en el tema.

Hospital-based COVID-19 registry: Design and implementation. Colombian experience.

Registries are essential to providing valuable clinical and epidemiological decisions. Designing a registry is challenging because it is time-consuming and resource-intensive, particularly in low- and middle-income countries. Here, we described our experience with the rationale, design, and implementation of a hospital-based COVID-19 registry in Cali, Colombia. We designed and implemented a hospital-based registry over a dynamic web-based structure to record all sociodemographic, clinical, and laboratory tests, imaging, treatment, and outcomes of SARS-CoV-2. We included 4458 confirmed COVID-19 cases of 18 years and older from March 2020 to March 2021. The median age was 48 years. The most frequent comorbidities were hypertension, obesity, and diabetes. The ICU admission rate was 19%, and the in-hospital mortality rate was 20%. The implemented strategies provided rapid and reliable information collection for the registry of emerging studies from the different clinical areas. Regular data quality and feedback are essential to ensure the reliability of the information. The integration of automatic data extraction reduces time consumption in information gathering and resources.

A comparison of resource use of insured and uninsured venezuelan migrants: evidence from the hospital setting.

BACKGROUND: There is no characterization of resource use in the hospital setting for immigrants in Colombia, we aimed to describe the resource use by Venezuelan immigrants, comparing those enrolled in the national health insurance system with those with and without the ability to pay. METHODS: Retrospective review in the billing data system of our Hospital from 2011 to 2020. We collected information for 6,837 hospital episodes associated with 1,022 Venezuelan patients, hospital's billing information for all services rendered was extracted. RESULTS: The mean cost per patient event were 4,595 USD for those without the ability to pay, costing 2.37 times more than a legal resident insured. Care in the ICU, inpatient days, surgery, and OB-GYN department consume most resources provided to vulnerable migrants. DISCUSSION: Enrolment in the national health insurance may allow better access to health services by vulnerable Venezuelan migrants and thus reduce resource use for the health system.

Safe and effective re-use policy for high-efficiency filtering facepiece respirators (FFRS): Experience of one hospital during the Covid-19 pandemic in 2020.

The high transmissibility rate of the Severe Acute Respiratory Syndrome Coronavirus 2 facilitated an exponential growth in the number of infections, posing a tremendous threat to healthcare systems across the world. The use of Non-oil 95% efficiency (N95) respirators demonstrated to reduce the risk of virus transmission. The escalated demand in N95 respirators during 2020 generated a massive shortage worldwide which resulted in serious implications, one being an increase in healthcare providers' costs. In response, various optimization strategies were implemented. This study aimed to assess the implementation of a safe and effective re-use policy for high-efficiency filtering facepiece respirators (FFRs) in a high-complexity university hospital in 2020. Associated costs were estimated through a descriptive accounting analysis of resources saved. Acceptability, appropriateness, and feasibility rates were 80.5%, 78.8%, and 83.6%, respectively. With an implementation cost of approximately 10,000 USD, there was a 56.1% reduction in FFRs consumption, compared with a non-policy scenario, with savings exceeding 500,000 USD in 2020. In a pandemic scenario where it is vital to spare resources, a FFRs rational use policy demonstrated to be a highly cost-efficient alternative in order to save resources without increasing contagion risk among healthcare workers.

Increase in direct costs for health systems due to lupus nephritis: the case of Colombia.

OBJECTIVE: Lupus nephritis is one of the most severe complications of systemic lupus erythematosus and it has been estimated that can occur in up to 60% of patients. Direct costs of lupus nephritis have not been studied in developing countries. This study aimed to describe lupus nephritis direct costs in Colombia. METHODS: Administrative data from two Colombian health maintenance organizations for 2014 and 2015 was obtained. An algorithm based on the International Statistical Classification of Diseases and Related Health Problems 10th revision codes was developed to identify patients with lupus nephritis and lupus nephritis under study. RESULTS: The average annual per-patient, all-claims, all-cause direct cost for lupus nephritis was US$ 12,624, 7.5 times higher than the average lupus patient without lupus nephritis. For lupus nephritis cases under study, estimated direct cost was US$ 3,664, 2 times higher than average lupus patient in Colombia. Difference in lupus nephritis patients is mainly accounted for the cost and frequency of procedures, exceeding by a factor of 5 the cost for durable medical equipment and the cost for drugs, respectively. CONCLUSION: Lupus patients who progress to lupus nephritis stage increased seven-fold the average annual per-patient, all-claims, and all-cause direct cost for the Colombian health system.

COVID-19 response in Colombia: Hits and misses.

Introduction: Colombia has been hit particularly hard by the COVID-19 pandemic, being ranked 22nd among 187 countries in deaths per 100,000 people by February 2022. The country has also experienced the worst economic recession in its history, with real GDP contracting 7% in 2020. This paper describes Colombia's pre-pandemic context and the overall effect of the pandemic on health and economic indicators and examines the government's response to COVID-19. Methods: Descriptive chronologic policy analysis on the COVID-19 pandemic in Colombia and the measures and interventions implemented, using publicly available secondary data from Colombia's official agencies and international sources published from March 2020 to February 2022. Results: The Colombian healthcare system increased its capacity in terms of infrastructure and human resources (from 8.6 ICU beds per 100,000 pre-pandemic to 21.9 in 2020, from 1.7 to 1.3 per 1000 doctors and nurses, respectively in 2019 to 1.8 and 1.5 per 1000 in 2020). The government commenced the National Vaccination Strategy on February 17, 2021, despite a slow start it managed to fully vaccinate 65.1% of its population, including Venezuelan immigrants, by February 2022. Conclusions: Colombia's response to the pandemic combines hits and misses. The country organized an early and robust response; increased its healthcare system capacity; designed a risk-based, equitable, and inclusive national vaccination strategy; and introduced a flexible and responsive vaccine rollout. However, the government chose the wrong timing for reform, implemented a long and unpredictable lockdown, was late to procure COVID-19 vaccines and has not appropriately tackled vaccine hesitancy. Public interest summary: Colombia has been hit particularly hard by the COVID-19 pandemic, with over 138,000 COVID-19 deaths and over 6 million cases by the end of February 2022. According to number of deaths per 100,000 people, Colombia ranks 22nd in the world, among 187 countries. The country has also experienced the worst economic recession in its history. The Colombian healthcare system has been able to cope with a high number of COVID-19 cases without collapsing, but some public health indicators deteriorated. Colombia's response to the pandemic combines hits and misses. The country organized an early and robust response; increased its healthcare system capacity; designed a risk-based, equitable, and inclusive national vaccination strategy; and introduced a flexible and responsive vaccine rollout. As of February 2022, Colombia has fully vaccinated 65.1% of its population. However, the government chose the wrong timing for a tax reform, implemented a long and unpredictable lockdown, was late to procure COVID-19 vaccines and has not appropriately tackled vaccine hesitancy, which certainly contributed to its undesirable position in the mortality world raking.

Eficiencia en organizaciones prestadoras de servicios de salud: ilustración de casos en el contexto colombiano

Los sistemas de salud comparten una preocupación mundial: la sostenibilidad financiera. El costo de oportunidad de los recursos públicos en escenarios de escasez demanda de académicos, hacedores de políticas y administradores en salud para buscar ineficiencias y corregirlas. Este artículo presenta un resumen de literatura de marcos conceptuales para entender e identificar ineficiencias en los sistemas de salud. También resume algunos hallazgos para Colombia, publicados en la literatura gris, e ilustra ejemplos de detección y corrección de ineficiencias en el ámbito de la prestación de servicios de salud en el país. En la mayoría de los casos ilustrados no se requieren cuantiosas inversiones; en su lugar, se requiere voluntad y liderazgo para la integración y coordinación de equipos de trabajo y el seguimiento de guías y protocolos de práctica clínica; apoyo institucional a procesos innovadores y compromiso institucional e investigación en mejores prácticas. Se resalta la necesidad de un cambio de cultura en las organizaciones prestadoras de servicios de salud hacia la medición con información para la toma de decisiones basada en evidencia.

Health systems around the world share a common concern: financial sustainability. The opportunity cost of public funds in the context of scarcity, demands from scholars, policy-makers and health services managers to actively seek for inefficient use of resources and for its correction. This paper presents a summary of the literature on conceptual frameworks to understand and identify possible sources of inefficiency in health systems. It also highlights some facts published in the grey literature for Colombia. Lastly, it illustrates with examples from the hospital context in Colombia several cases in which inefficiencies were detected and corrected. It is found that in the majority of cases no massive investments are required, instead what is required is agency and leadership to better integrate and coordínate teams to follow clinical practice protocols; institutional support to innovative processes and institutional support to look for best practices. The need for a cultural change within healthcare services providers towards information-based measurement and evidence-based decision-making.

Decreases in resource use after implementing an interdisciplinary management program for patients with placenta accreta spectrum.

OBJECTIVE: Placenta accreta spectrum (PAS) often causes severe morbidity and demands the availability of abundant health resources. Research has shown that the participation of experienced interdisciplinary groups in specialized centers improves clinical outcomes. Our objective is to measure resource use variation after implementing an interdisciplinary management program for this condition. METHODS: Using detailed billing information, hospital care resource use was measured at constant prices for women with PAS who were treated between 2011 and 2019. Cases were classified before (Group 1) and after (Group 2) the implementation of the program. A third group included women with intraoperative MAP findings (Group 3). Comparisons were made using descriptive statistics. RESULTS: The mean reduction in resource use after the program was 16.5% per patient. The program also reduced variability in resource use as measured by the standard deviation and the coefficient of variation, which decreased by 55.2% and 46.3%, respectively. CONCLUSION: The interdisciplinary management of patients affected by PAS in experienced hospitals is associated with a reduction in resource use and variability.

Increase in direct costs for health systems due to lupus nephritis: the case of Colombia

ABSTRACT Objective Lupus nephritis is one of the most severe complications of systemic lupus erythematosus and it has been estimated that can occur in up to 60% of patients. Direct costs of lupus nephritis have not been studied in developing countries. This study aimed to describe lupus nephritis direct costs in Colombia. Methods Administrative data from two Colombian health maintenance organizations for 2014 and 2015 was obtained. An algorithm based on the International Statistical Classification of Diseases and Related Health Problems 10th revision codes was developed to identify patients with lupus nephritis and lupus nephritis under study. Results The average annual per-patient, all-claims, all-cause direct cost for lupus nephritis was US$ 12,624, 7.5 times higher than the average lupus patient without lupus nephritis. For lupus nephritis cases under study, estimated direct cost was US$ 3,664, 2 times higher than average lupus patient in Colombia. Difference in lupus nephritis patients is mainly accounted for the cost and frequency of procedures, exceeding by a factor of 5 the cost for durable medical equipment and the cost for drugs, respectively. Conclusion Lupus patients who progress to lupus nephritis stage increased seven-fold the average annual per-patient, all-claims, and all-cause direct cost for the Colombian health system.

Parkinson's disease prevalence, age distribution and staging in Colombia.

Parkinson's disease (PD) has the second highest prevalence among neurodege - nerative diseases. In Colombia, PD population dynamics are currently unknown. Health records offer a unique resource to study frequency and multi-morbidity of chronic diseases. The aim of this research is to estimate prevalence and staging using administrative data (AD) provided by Health Maintenance Organizations (HMOs). A cross-sectional study was conducted using 2015 AD from two Colombian HMOs (4.312.928 beneficiaries, 9.01% of the affiliated Colombian population). PD prevalence and severity was estimated by age and sex. Prevalence was adjusted to WHO demographics. Age-adjusted PD prevalence was 205.89 per 100.000 inhabitants. Prevalence increment of 62.13% was found between those aged ≥40 years and those aged ≥50 years. Similarly, each extra decade (50-80+) represented an increment of 83.65%, 80.95%, and 35.10%. Between 40 and 89 years, males exhibited a significantly higher PD prevalence compared to females. Advanced PD was more frequent as age increased from 3.77% in the group between 40 to 49 years to 25.86% in those older than 89 years. More common related comorbidities were arterial hypertension, diabetes, and psychiatric disorders; the first two increased their frequency with age, and the last one maintained its prevalence across all age groups. AD sets are useful to estimate the prevalence and staging of PD. Prevalence of PD in Colombia is higher in men and increases with age, as well as disease severity.

Analyzing Factors Associated with Trash Pickers' Health Status: Census Data in a Major City in Colombia.

This study aims to identify factors associated with the probability of trash pickers feeling physically or mentally ill and assesses differences by gender. To achieve these, we estimated multivariate regression models by using data from a census' update of 3109 trash pickers in Cali-Colombia in 2015. Outcomes are defined by two binary variables for whether the trash picker reports 14 or more days during the last month with physical and mental illness. Factors included demographic, family, psychological, socioeconomic and job characteristics. We found gender differences in several risk factors. Also a strong link between physical and mental health was found. Trash picker women are more vulnerable than men, public policy interventions aimed at prevention and treatment of mental health problems will have a positive side effect on their physical and mental health.

Direct cost of Parkinson's disease in a health system with high judicialization: evidence from Colombia.

Objective: To estimate all-claims-all-conditions expenditures paid for by health plans for patients suffering from Parkinson´s disease (PD). Methods: Using administrative claims data from two health maintenance organizations for 2014 and 2015 in Colombia, we identified 2,917 patients with PD by applying an algorithm that uses International Statistical Classification of Diseases and Related Health Problems and Anatomical Therapeutic Chemical Classification System codes. Descriptive statistics were applied to compute unadjusted all-cause median costs. A generalized linear model was used to estimate adjusted and attributable direct costs of advanced PD. Results: Approximately 30% of the all-cause direct costs were associated with technologies not included in universal health coverage benefit packages. In 2015, the annual median interquartile range per patient all-cause direct costs to insurers was USD1,576 (605-3,617). About 16% of patients had advanced PD. Regression analysis estimated that additional costs attributable to advanced PD was USD3,416 (p = 0.000). Multimorbidity was highly prevalent, and 96% of PD patients had at least one other chronic condition. Conclusions: In the context of high judicialization, patients suffering from PD must increasingly use the judicial system to access treatment. To promote more equitable and efficient access benefit packages, developing countries must consider more thoroughly the needs of these patients.

Mental health, interpersonal trust and subjective well-being in a high violence context.

This paper assesses whether two factors of wellbeing, social capital (interpersonal trust and social networks) and subjective well-being are associated with frequent mental distress and if there are any mediating effects by gender in a city of high urban violence. This paper relies on data that comes from a sample of over 1300 people representative by gender, race/ethnicity, and socioeconomic breakdown of the city of Cali in Colombia, which was collected in 2017 through face-to-face surveys. Our study uses logistic regression with fixed-effects at the district level to control for unobserved time-invariant factors. At the individual level, our analyses account for social and demographic context variables. The dependent variable is mental distress, defined as having 14 or more days feeling mentally ill in the previous 30-day period. Independent variables of interest are "interpersonal trust in unknown people" measured in a scale 0-10 and, social networks measured using the number of family members and close friends and subjective well-being through a question about life satisfaction in a scale 0-10. We find risk factors for mental health distress were low trust in unknown people, low life satisfaction, high levels of depression, living in cohabitation, being female, not having children, and living in middle socio-economic status. The odds of feeling mentally ill decreased as trust in unknown people increased by each unit in the trust scale (OR: 0.92). There were gender differences, with women's mental health being less likely to be affected by lack of interpersonal trust (OR: 0.94) than men (OR: 0.76). Our study suggests that actions aimed at fostering interpersonal trust in unknown people could positively affect mental health distress for both males and females. In the context of high urban violence, our study shows that men are more likely to benefit from such actions.

Comparing the Medicaid Prospective Drug Utilization Review Program Cost-Savings Methods Used by State Agencies in 2015 and 2016.

BACKGROUND: The Medicaid Drug Utilization Review (DUR) program is a 2-phase process conducted by Medicaid state agencies. The first phase is a prospective DUR process and involves electronically monitoring prescription drug claims to identify prescription-related problems, such as therapeutic duplication, contraindications, incorrect dosage, or duration of treatment. The second phase is a retrospective DUR involving ongoing, periodic examinations of claims data to identify patterns of fraud, abuse, underutilization, drug-drug interaction, and medically unnecessary care, and implement corrective actions when needed. The Centers for Medicare & Medicaid Services requires each state to measure the prescription drug cost-savings generated from its DUR programs annually, but it provides no methodology for doing so. An earlier article compared the methodologies used by states to measure cost-savings in their retrospective DUR program in fiscal years 2014 and 2015. OBJECTIVE: To describe and synthesize the methodologies used by states to measure cost-savings using their Medicaid prospective DUR program in federal fiscal years 2015 and 2016. METHODS: For each state, we downloaded from Medicaid's website the cost-savings methodologies included in the Medicaid DUR 2015 and 2016 reports. We then reviewed and synthesized the reports. Methods described by the states were classified into a unique group based on the methodology used, except for Arkansas and Connecticut, which were classified in more than 1 category for the same period. RESULTS: Currently, 3 different methodologies are being used by states. In 2015 and 2016, the most common methodology used (by 18 states) was the calculation of total claim rejections and subtracting claim resubmissions at the amount actually paid. The comparisons of DUR program cost-savings among states are unreliable, because the states lack a common methodology in the way they measure their performance. CONCLUSIONS: Considering the lack of methodologic consistency among states in measuring the savings in the Medicaid DUR program shown in this analysis, the federal government must lead an effort to define a unique methodology to measure cost-savings in its entire DUR program. This will help to improve the measure of savings among states and understand how this program is performing in that matter.