Prognostic role of renal replacement therapy among hospitalized patients with heart failure in the Brazilian national public health system.

Introduction: Data on patients hospitalized with acute heart failure in Brazil scarce. Methods: We performed a cross-sectional, retrospective, records-based study using data retrieved from a large public database of heart failure admissions to any hospital from the Brazilian National Public Health System (SUS) (SUS Hospital Information System [SIHSUS] registry) to determine the in-hospital all-cause mortality rate, in-hospital renal replacement therapy rate and its association with outcome. Results: In total, 910,128 hospitalizations due to heart failure were identified in the SIHSUS registry between April 2017 and August 2021, of which 106,383 (11.7%) resulted in in-hospital death. Renal replacement therapy (required by 8,179 non-survivors [7.7%] and 11,496 survivors [1.4%, p < 0.001]) was associated with a 56% increase in the risk of death in the univariate regression model (HR 1.56, 95% CI 1.52 -1.59), a more than threefold increase of the duration of hospitalization, and a 45% or greater increase of cost per day. All forms of renal replacement therapy remained independently associated with in-hospital mortality in multivariable analysis (intermittent hemodialysis: HR 1.64, 95% CI 1.60 -1.69; continuous hemodialysis: HR 1.52, 95% CI 1.42 -1.63; peritoneal dialysis: HR 1.47, 95% CI 1.20 -1.88). Discussion: The in-hospital mortality rate of 11.7% observed among patients with acute heart failure admitted to Brazilian public hospitals was alarmingly high, exceeding that of patients admitted to North American and European institutions. This is the first report to quantify the rate of renal replacement therapy in patients hospitalized with acute heart failure in Brazil.

The impact of COPD on the private healthcare system in Brazil: an economic analysis / Impacto da DPOC no sistema de saúde privado no Brasil: uma análise econômica

Objective: To assess healthcare resource utilization and hospitalization costs of patients with chronic obstructive pulmonary disease (COPD) exacerbations in the Brazilian private healthcare system. Methods: A retrospective cohort study, considering data from an administrative database of a private company (Orizon). Patients aged ≥40 years old and with at least one COPD-related claim identified by the ICD-10 code (J40 to J44) at any time during the eligibility period (January/2010 to December/2013) were included in the analysis. Follow-up was performed until December/2014, death or inactivation of a health plan. Sociodemographic characteristics, number of emergency visits, hospital admissions (number and length of stay), length of hospital stay in an intensive care unit (ICU), number of severe COPD exacerbations, therapeutic approach, and hospitalization costs were assessed. Results: The analysis included 8,254 COPD patients. Emergency visits, hospital admission, and exacerbation rates were 0.4, 0.2, and 0.1 per person-year, respectively. The mean length of hospital stays and the length of stay of patients requiring or not ICU stay were 16.6 (SD = 77.0), 8.7 (SD = 36.9), and 27.6 (SD = 109.7), respectively. Mean costs associated to emergency department visits and hospitalizations were 258.2 BRL (SD = 383.1) and 38,165.4 BRL (SD = 124,683.5), respectively. Hospitalizations costs without ICU stay were 11,810.1 BRL (SD = 31,144.1) and 74,585.3 BRL (SD = 182,808.1) for those with ICU utilization. Conclusion: Costs for COPD management during disease exacerbation are very high and may reach almost 75 thousand BRL per hospitalization. The prevention of COPD exacerbations and better disease control may reduce the economic burden on the private healthcare system in Brazil.

Objetivo: Avaliar a utilização de recursos e custos de pacientes com exacerbação da doença pulmonar obstrutiva crônica (DPOC) no sistema de saúde suplementar (SSS) do Brasil. Métodos: Estudo de coorte retrospectiva, considerando banco de dados administrativo de uma empresa privada (Orizon). Pacientes com ≥40 anos e pelo menos um registro de admissão relacionado à DPOC identificado com CID-10 J40-J44, entre janeiro/2010 e dezembro/2013, foram incluídos e acompanhados até dezembro/2014, morte ou inativação no plano. Características sociodemográficas, número de visitas de emergência, admissões hospitalares (número e tempo de hospitalização), tempo de hospitalização em unidade de terapia intensiva (UTI), número de exacerbações graves, estratégias terapêuticas e custos hospitalares foram as variáveis analisadas. Resultados: A análise incluiu 8.254 pacientes com DPOC. As taxas de visita à emergência, internação hospitalar e exacerbação da doença foram de 0,4, 0,2 e 0,1 por pessoa-ano, respectivamente. Os tempos médios de hospitalização, hospitalização sem utilização de UTI e hospitalização com necessidade de UTI foram de 16,6 (DP = 77,0), 8,7 (DP = 36,9) e 27,6 (DP = 109,7) dias, respectivamente. Os custos médios relacionados à visita de emergência e por hospitalização foram de 258,2 BRL (DP = 383,1) e 38.165,4 BRL (DP = 124.683,5), respectivamente. Os custos para pacientes que não utilizaram UTI foram de 11.810,1 BRL (DP = 31.144,1) e de 74.585,3 BRL (DP = 182.808,1) para aqueles com necessidade desse serviço. Conclusão: Os custos para o manejo dos pacientes com exacerbação da DPOC são muito elevados, podendo chegar a 75.000 BRL por hospitalização. A prevenção de exacerbações e o melhor controle da doença podem reduzir esse impacto econômico no SSS.

The economic impact of asthma on private healthcare system in Brazil: Economic impact of asthma in Brazil.

To assess healthcare resource utilization and costs of patients with asthma in Brazilian Supplementary Healthcare System, focusing on hospitalization data. Retrospective cohort study, using data from an administrative database of a private company (Orizon). Patients aged ≥ 12 years with at least one record of emergency visit/hospitalization in the database with the ICD-10 J45 between January/2010 and June/2015 were included and followed until June/2016, death or inactivation of health plan. Sociodemographic characteristics, emergency visit and hospital admission per patient per year (exacerbation rate), physician visit with a procedure, exams, length of hospitalization (with/without intensive care unit (ICU)), and in-hospital treatments were assessed. A total of 54,568 patients were included in this analysis. Regarding resource utilization, emergency visit and hospital admission rates of 0.34 and 0.04 per person-year were observed, respectively. Mean length of hospital stay were 8.82 (SD = 36.48), 5.24 (SD = 19.06) and 19.53 (63.89) days for hospitalizations in general, without and with ICU, respectively. An exacerbation rate of 0.36 per person year was observed with a mean cost per episode of 3178 Brazilian Real (BRL) (SD = 31,667). Mean cost related to emergency department visits was estimated at 293 BRL (SD = 328). Hospitalization costs were stratified by the need of ICU and values observed were of 9307 BRL (SD = 18,979) without ICU, and 75,252 BRL (SD = 174,248) with ICU need. Asthma exacerbations may cost ~75,000 BRL for an ICU-dependent event in the Supplementary Healthcare System. To improve disease control may reduce disease burden for both healthcare system and patients.

Severe asthma and eligibility for biologics in a Brazilian cohort.

OBJECTIVE: This study aims to describe the eligibility for biologic therapies for severe asthma (SA) in a cohort of patients attending the Program for Control of Asthma (ProAR) in Bahia, Brazil. METHODS: Data from SA patients (≥18 years old) attending the ProAR, that were included in a case-control study conducted from 2013 to 2015, were used to reassess patients according to a modified ERS/ATS 2014 SA criteria. Patients were then classified according to the eligibility for SA biological therapy based on current prescription labels. RESULTS: From 544 patients in the cohort, 531 (97.6%) were included and 172 (32.4%) were identified as SA patients according to the ERS/ATS 2014 modified criteria. Of these 172 patients, 69 (40.1%) were ineligible for any of the biologicals approved for asthma (omalizumab, mepolizumab, reslizumab and benralizumab), 60 (34.9%) patients were eligible for one of the biological therapies, and 10 (5.8%) patients were eligible for all biological therapies. CONCLUSIONS: More than half of patients with SA were eligible for biologic therapy in our study, but none of them received this form of treatment. Almost half of them were not eligible to any of the approved biologics, however. The variability and overlap in patients' eligibility highlight the importance of evaluating each patient individually for a more personalized treatment approach. While there is a need to increase access for some of those eligible that may really need a biologic treatment, continuous efforts are required to develop alternatives to those who are not eligible.

Key factors associated with uncontrolled asthma - the Asthma Control in Latin America Study.

Objective: This study aimed to estimate asthma control at specialist treatment centers in four Latin American countries and assess factors influencing poor asthma control.Methods: Patients aged ≥12 years with an asthma diagnosis and asthma medication prescription, followed at outpatient specialist centers in Argentina, Chile, Colombia, and Mexico, were included. The study received all applicable ethical approvals. The Asthma Control Test (ACT) was used to classify patients as having controlled (ACT 20-25) or uncontrolled (ACT ≤19) asthma. Frequency and statistical tests were used to assess the association between hospital admissions/exacerbations/emergency department (ED) visits and uncontrolled asthma; multivariate logistic regression was used to assess the association of uncontrolled asthma with clinical/demographic variables.Results: A total of 594 patients were included. Overall controlled-asthma prevalence was 43.4% (95% confidence interval [CI]: 39.0, 47.4). Patients with uncontrolled asthma were more likely to be women (adjusted odds ratio [aOR]: 1.85; p = 0.003), non-white (aOR: 2.14; p < 0.001), obese (aOR: 1.71; p = 0.036), to have a low monthly family income (aOR: 1.75; p = 0.004), to have severe asthma (aOR:1.59; p = 0.26), and, compared with patients with controlled asthma, to have a higher likelihood of asthma exacerbations (34.5% vs. 15.9%; p < 0.001), hospital admissions (6.9% vs. 3.1%; p = 0.042), and ED visits (34.5% vs. 15.9%; p < 0.001) due to asthma.Conclusions: Even in specialist ambulatory services, fewer than half of patients were classified as having controlled asthma. The proportion of uncontrolled patients varied according to clinical and demographic variables.

Asthma severity in four countries of Latin America.

BACKGROUND: In Latin America, there is scarce information about severe asthma (SA) according to the ERS/ATS 2014 criteria. This study aimed to compare the demographic, socio, clinical characteristics, treatment, and use of healthcare resources between SA and non-severe asthma (NSA) patients in Argentina, Colombia, Chile and Mexico. METHODS: A cross-sectional study was conducted including 594 asthma patients from outpatient specialized sites. A descriptive analysis was performed comparing SA patients and NSA. Chi-square and Mann Whitney tests were used to assess associations between asthma severity and outcome variables. RESULTS: Using ERS/ATS 2014 criteria, 31.0% of the patients were identified as SA. SA patients were older at diagnosis (mean age 31.64 years vs 24.71 years, p < 0.001) and had higher proportion of uncontrolled asthma than the NSA patients (64.1% vs 53.2%, p < 0.001). SA patients reported a significantly higher proportion of both hospital admission and emergency room (ER) visits due to asthma in the last year, compared with NSA patients, 8.7% vs. 3.7% (p = 0.011) and 37.0% vs. 21.7% (p < 0.001), respectively. CONCLUSIONS: SA patients were older, had greater proportions in some comorbidities and experienced increased healthcare utilization. Also, our results showed that even in patients using the last steps of treatment (GINA step 4 or 5), there was still a higher proportion of uncontrolled disease.

Trend of self-reported asthma prevalence in Brazil from 2003 to 2013 in adults and factors associated with prevalence / Tendência da prevalência de asma autorreferida no Brasil de 2003 a 2013 em adultos e fatores associados à prevalência

ABSTRACT Objectives: To determine the trend of self-reported asthma diagnosed prevalence and to describe the factors associated with asthma in Brazilian adults. Method: Epidemiological cross-sectional study based on databases analysis from three national household surveys: Pesquisa Nacional por Amostra de Domicílios (PNAD) 2003, PNAD 2008 and Pesquisa Nacional de Saúde (PNS) 2013. Participants between 18-45 years old were included. Trend analysis of asthma diagnosed prevalence was conducted using a logistic general linear model. A hierarchical logistic regression model was used to select factors significantly associated with asthma prevalence. Results: Asthma diagnosed prevalence was 3.6% (2003), 3.7% (2008) and 4.5% (2013), showing a statistically significant increased trend. Asthma diagnosed prevalence also increased when analysed by gender (annual change for men: 2.47%, p < 0.003; women: 2.16%, p < 0.001), urban area (annual change for urban: 2.15%, p < 0.001; rural: 2.69%, p = 0.072), healthcare insurance status (annual change without healthcare insurance: 2.18%, p < 0.001; with healthcare insurance: 1.84%, p = 0.014), and geographic regions (annual change North: 4.68%, p < 0.001; Northeast: 4.14%, p < 0.001; and Southeast: 1.84%, p = 0.025). Female gender, obesity, living in urban areas and depression were associated with asthma diagnosed prevalence. Discussion: PNAD and PNS surveys allow for a very large, representative community-based sample of the Brazilian adults to investigate the asthma prevalence. From 2003 to 2013, the prevalence of self-reported physician diagnosis of asthma increased, especially in the North and Northeast regions. Gender, region of residence, household location (urban/rural), obesity, and depression diagnosis seem to play significant roles in the epidemiology of asthma in Brazil.

RESUMO Objetivos: Determinar a tendência da prevalência de diagnóstico de asma autorreferida e descrever os fatores associados à asma em adultos brasileiros. Método: Estudo transversal de análise de dados de três pesquisas domiciliares nacionais: Pesquisa Nacional por Amostra de Domicílios (PNAD) 2003, PNAD 2008 e Pesquisa Nacional de Saúde (PNS) 2013. Participantes entre 18 e 45 anos foram incluídos. A análise de tendência da prevalência do diagnóstico de asma foi realizada utilizando modelo logístico linear. Aplicou-se o modelo de regressão logística hierárquico para selecionar fatores significativamente associados à prevalência de asma. Resultados: A prevalência do diagnóstico de asma foi de 3,6% (2003), 3,7% (2008) e 4,5% (2013), apresentando tendência de elevação significativa. A prevalência do diagnóstico de asma também se elevou quando analisada por sexo (variação anual entre homens: 2,47%, p < 0,003; mulheres: 2,16%, p < 0,001), área urbana (variação anual: 2,15% p < 0,001), plano de saúde (variação anual sem plano: 2,18%, p < 0,001; com plano: 1,84%, p = 0,014) e regiões geográficas (variação anual Norte: 4,68%, p < 0,001; Nordeste 4,14%, p < 0,001; e Sudeste 1,84%, p = 0,025). Sexo feminino, obesidade, viver em áreas urbanas e depressão foram associados positivamente com a prevalência de diagnóstico de asma. Discussão: PNAD e PNS são bases populacionais representativas de adultos brasileiros que possibilitam a investigação da prevalência de asma. De 2003 a 2013, a prevalência de diagnóstico autorreferido de asma aumentou, especialmente nas regiões Norte e Nordeste. Sexo, região geográfica e área de residência (urbana/rural), obesidade e diagnóstico de depressão parecem desempenhar papéis significativos na epidemiologia da asma no Brasil.

Pulmonary arterial hypertension in Latin America: epidemiological data from local studies.

BACKGROUND: Pulmonary arterial hypertension is a rare, progressive disease with poor prognosis. However, there is limited information available on the characteristics of PAH patients outside of North America and Europe. This is particularly important as researchers have described that there are potential geographical and regional differences which are vital to consider in the design of clinical trials as well as PAH treatment. The aim of this study was to describe the epidemiology of PAH (PH group 1) in Latin America. METHODS: A search of electronic databases for studies published in English, Spanish or Portuguese was conducted specifying publication dates from the 1st of January 1987 until 10th October 2016. Two authors independently assessed papers for inclusion and extracted data. A narrative synthesis of the findings was conducted. RESULTS: The search revealed 22 conference abstracts and articles, and on application of the inclusion criteria, six conference abstracts and articles were included in the final review. Studies/registries were based in Argentina, Brazil and Chile. In contrast to the available literature from developed countries, in Latin America, most patients were diagnosed at younger age; nevertheless, the higher prevalence of idiopathic PAH (IPAH) and the advanced stage of the disease at diagnosis were comparable to the existing literature, as the long term survival, despite the lower availability of targeted therapies. CONCLUSION: This study highlights the regional characteristics in the epidemiology of group 1 PH. The recognition of these differences should be considered when developing clinical guidelines and extrapolating diagnostic and treatment algorithms. Equitable access to health care and therapies are also issues that need to be addressed in Latin America. Information coming from a large prospective registry representing the different populations in Latin America is of critical importance to increase disease awareness in the region and improve diagnosis and management.

Trend of self-reported asthma prevalence in Brazil from 2003 to 2013 in adults and factors associated with prevalence.

OBJECTIVES: To determine the trend of self-reported asthma diagnosed prevalence and to describe the factors associated with asthma in Brazilian adults. METHOD: Epidemiological cross-sectional study based on databases analysis from three national household surveys: Pesquisa Nacional por Amostra de Domicílios (PNAD) 2003, PNAD 2008 and Pesquisa Nacional de Saúde (PNS) 2013. Participants between 18-45 years old were included. Trend analysis of asthma diagnosed prevalence was conducted using a logistic general linear model. A hierarchical logistic regression model was used to select factors significantly associated with asthma prevalence. RESULTS: Asthma diagnosed prevalence was 3.6% (2003), 3.7% (2008) and 4.5% (2013), showing a statistically significant increased trend. Asthma diagnosed prevalence also increased when analysed by gender (annual change for men: 2.47%, p < 0.003; women: 2.16%, p < 0.001), urban area (annual change for urban: 2.15%, p < 0.001; rural: 2.69%, p = 0.072), healthcare insurance status (annual change without healthcare insurance: 2.18%, p < 0.001; with healthcare insurance: 1.84%, p = 0.014), and geographic regions (annual change North: 4.68%, p < 0.001; Northeast: 4.14%, p < 0.001; and Southeast: 1.84%, p = 0.025). Female gender, obesity, living in urban areas and depression were associated with asthma diagnosed prevalence. DISCUSSION: PNAD and PNS surveys allow for a very large, representative community-based sample of the Brazilian adults to investigate the asthma prevalence. From 2003 to 2013, the prevalence of self-reported physician diagnosis of asthma increased, especially in the North and Northeast regions. Gender, region of residence, household location (urban/rural), obesity, and depression diagnosis seem to play significant roles in the epidemiology of asthma in Brazil.

The PLATINO study: description of the distribution, stability, and mortality according to the Global Initiative for Chronic Obstructive Lung Disease classification from 2007 to 2017.

BACKGROUND: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report provides a framework for classifying COPD reflecting the impacts of disease on patients and for targeting treatment recommendations. The GOLD 2017 introduced a new classification with 16 subgroups based on a composite of spirometry and symptoms/exacerbations. METHODS: Data from the population-based PLATINO study, collected at baseline and at follow-up, in three sites in Latin America were analyzed to compare the following: 1) the distribution of COPD patients according to GOLD 2007, 2013, and 2017; 2) the stability of the 2007 and 2013 classifications; and 3) the mortality rate over time stratified by GOLD 2007, 2013, and 2017. RESULTS: Of the 524 COPD patients evaluated, most of them were classified as Grade I or II (GOLD 2007) and Group A or B (GOLD 2013), with ≈70% of those classified as Group A in GOLD 2013 also classified as Grade I in GOLD 2007 and the highest percentage (41%) in Group D (2013) classified as Grade III (2007). According to GOLD 2017, among patients with Grade I airflow limitation, 69% of them were categorized into Group A, whereas Grade IV patients were more evenly distributed among Groups A-D. Most of the patients classified by GOLD 2007 remained in the same airflow limitation group at the follow-up; a greater temporal variability was observed with GOLD 2013 classification. Incidence-mortality rate in patients classified by GOLD 2007 was positively associated with increasing severity of airflow obstruction; for GOLD 2013 and GOLD 2017 (Groups A-D), highest mortality rates were observed in Groups C and D. No clear pattern was observed for mortality across the GOLD 2017 subgroups. CONCLUSION: The PLATINO study data suggest that GOLD 2007 classification shows more stability over time compared with GOLD 2013. No clear patterns with respect to the distribution of patients or incidence-mortality rates were observed according to GOLD 2013/2017 classification.

Access to continued-use medication among older adults, Brazil.

OBJECTIVE To determine the prevalence and associated access factors for all continued-use prescription drugs and the ways in which they can be obtained. METHODS Data was obtained from the 2008 Household National Survey. The sample comprised 27,333 individuals above 60 years who reported that they used continued-use prescription drugs. A descriptive analysis and binary and multiple multinomial logistic regressions were performed. RESULTS 86.0% of the older adults had access to all the medication they needed, and among them, 50.7% purchased said medication. Those who obtained medication from the public health system were younger (60-64 years), did not have health insurance plans, and belonged to the lower income groups. It is remarkable that 14.0% of the subjects still had no access to any continued-use medication, and for those with more than four chronic diseases, this amount reached 22.0%. Those with a greater number of chronic diseases ran a higher risk of not having access to all the medication they needed. CONCLUSIONS There are some groups of older adults with an increased risk of not obtaining all the medication they need and of purchasing it. The results of this study are expected to contribute to guide programs and plans for access to medication in Brazil.

Access to continued-use medication among older adults, Brazil / Acesso a medicamentos de uso contínuo entre idosos, Brasil

OBJECTIVE To determine the prevalence and associated access factors for all continued-use prescription drugs and the ways in which they can be obtained. METHODS Data was obtained from the 2008 Household National Survey. The sample comprised 27,333 individuals above 60 years who reported that they used continued-use prescription drugs. A descriptive analysis and binary and multiple multinomial logistic regressions were performed. RESULTS 86.0% of the older adults had access to all the medication they needed, and among them, 50.7% purchased said medication. Those who obtained medication from the public health system were younger (60-64 years), did not have health insurance plans, and belonged to the lower income groups. It is remarkable that 14.0% of the subjects still had no access to any continued-use medication, and for those with more than four chronic diseases, this amount reached 22.0%. Those with a greater number of chronic diseases ran a higher risk of not having access to all the medication they needed. CONCLUSIONS There are some groups of older adults with an increased risk of not obtaining all the medication they need and of purchasing it. The results of this study are expected to contribute to guide programs and plans for access to medication in Brazil. .

OBJETIVO Analisar a prevalência e fatores associados com o acesso a medicamentos de uso contínuo e formas de sua obtenção. MÉTODOS Foram obtidos dados da Pesquisa Nacional por Amostras em Domicílio de 2008. A amostra foi composta por 27.333 indivíduos com idade acima de 60 anos que reportaram utilizar medicamentos de uso contínuo. Foram utilizados modelos de regressão logística multinomial binário e múltipla para análise dos dados. RESULTADOS Tiveram acesso a todos os medicamentos 86,0% dos idosos, dos quais 50,7% os obtiveram por compra. Aqueles que os obtiveram do sistema público de saúde eram mais jovens (60-64 anos), não tinham plano de saúde e pertenciam a grupos com menor renda. Dos idosos que usam medicamentos de uso contínuo, 14,0% não receberam nenhum dos medicamentos; para aqueles com mais de quatro doenças crônicas esse valor chegou a 22,0%; aqueles com maior número de morbidades crônicas tiveram maior risco de não conseguir todos os medicamentos. CONCLUSÕES Alguns grupos de idosos apresentam risco aumentado de não obter todos os medicamentos necessários e de comprar todos os medicamentos. Esses resultados podem orientar programas e planos de acesso a medicamentos no Brasil. .