Effect of age-related premium readjustment on health insurance cancellation in Brazil: Regression discontinuity approach.

Age is one of the most relevant observable risk attributes in determining the value of health insurance premiums. Empirical evidence indicates that the cost of health insurance is the leading cause of contract switching, which can compromise access to healthcare services and potentially result in treatment discontinuities. Using data from a Health Maintenance Organization in the Southern region of Brazil, we examined the effect of health plan price readjustment resulting from changes in the beneficiary's age group on disenrollment or switches to a more limited coverage plan. The estimates were obtained using the method of regression discontinuity. The main findings indicate that for age group transitions at 59 years old, the price readjustment effect led to an increase in contract cancellations and switching to cheaper plans. These findings highlight that an important consequence of the difference in premium sensitivity among age groups is that the exit of individuals from the health insurance sector is selective in age. The results of this paper can support policymaking to improve access to health insurance.

Family health strategy and equity in prenatal care: a population based cross-sectional study in Minas Gerais, Brazil.

BACKGROUND: Prenatal care coverage is still not universal or adequately provided in many low and middle income countries. One of the main barriers regards the presence of socioeconomic inequalities in prenatal care utilization. In Brazil, prenatal care is supplied for the entire population at the community level as part of the Family Health Strategy (FHS), which is the main source of primary care provided by the public health system. Brazil has some of the greatest income inequalities in the world, and little research has been conducted to investigate prenatal care utilization of FHS across socioeconomic groups. This paper addresses this gap investigating the socioeconomic and regional differences in the utilization of prenatal care supplied by the FHS in the state of Minas Gerais, Brazil. METHODS: Data comes from a probabilistic household survey carried out in 2012 representative of the population living in urban areas in the state of Minas Gerais. The sample size comprises 1,420 women aged between 13 and 45 years old who had completed a pregnancy with a live born in the last five years prior to the survey. The outcome variables are received prenatal care, number of antenatal visits, late prenatal care, antenatal tests, tetanus immunization and low birthweight. A descriptive analysis and logistic models were estimated for the outcome variables. RESULTS: The coverage of prenatal care is almost universal in catchment urban areas of FHT of Minas Gerais state including both antenatal visits and diagnostic procedures. Due to this high level of coverage, socioeconomic inequalities were not observed. FHS supplied care for around 80% of the women without private insurance and 90% for women belonging to lower socioeconomic classes. Women belonging to lower socioeconomic classes were at least five times more likely to receive antenatal visits and any of the antenatal tests by the FHS compared to those belonging to the highest classes. Moreover, FHS was effective in reducing low birthweight. Women who had prenatal care through FHS were 40% less likely to have a child with low birthweight. CONCLUSION: This paper presents strong evidence that FHS promotes equity in antenatal care in Minas Gerais, Brazil.

EQ-5D-3L as a health measure of Brazilian adult population.

PURPOSE: This study explores the use of EQ-5D-3L as a measure of population health status in a Brazilian region with significant socioeconomic, demographic, and epidemiological heterogeneity. METHODS: Data came from a study of 3363 literate individuals aged between 18 and 64 years living in urban areas of the state of Minas Gerais. Descriptive analysis and logistic and OLS regression models were performed to analyze the relationship between EQ-5D-3L (descriptive system and EQ VAS) and other health (self-assessed health status and 8 self-reported diagnosed chronic diseases), socioeconomic (educational level and economic class), and demographic (gender and age) measures. Additionally, a grade of membership (GoM) analysis was performed to identify multidimensional health profiles. RESULTS: A total of 76 health statuses were identified in the Brazilian population. The most prevalent one is full health (44 % of the sample). Elderly people, women, and individuals with poor health and lower socioeconomic conditions generally report more health problems in the EQ-5D-3L dimensions. The GoM analysis demonstrated that health status of older individuals is associated with the socioeconomic condition. Arthritis exhibited the strongest association with the EQ-5D-3L instrument. CONCLUSIONS: The results indicate that EQ-5D-3L is a good measure of health status for the Brazilian population. The instrument has a good discriminatory capacity in terms of demographic, socioeconomic, and health measures. The high prevalence of individuals with full health may indicate the presence of ceiling effect. However, this prevalence is smaller than that in other countries.

Cost components of school-based oral health-promoting programs: A systematic review protocol.

INTRODUCTION: Oral health-promoting school programs play a crucial role in achieving universal coverage of oral health care, by addressing oral diseases and promoting the well-being and quality of life of children and adolescents. However, a lack of studies has evaluated the costs associated with implementing these programs, which hinders decision-makers in adopting them on a large scale. This review aims to assess the cost components involved in school-based oral health-promoting programs. METHODS: This review will include studies that have conducted either partial or full economic evaluations, focusing on describing the cost components of oral health-promoting programs implemented in primary schools involving students aged 6 to 14. A systematic search was conducted across multiple databases: MEDLINE, The Cochrane Library, the Virtual Health Library, the NHS Economic Evaluation Database, Web of Science, Scopus, and EMBASE. Additionally, gray literature was searched using the Health Technology Assessment Database. Two independent reviewers will screen the titles and abstracts, followed by a full-text review based on predefined inclusion criteria. Data extraction and critical appraisal evaluation will also be carried out independently by two reviewers. In case of disagreements, the reviewer team will resolve them through discussion. DISCUSSION: The systematic review resulting from this protocol aims to provide evidence regarding the cost components and necessary resources for implementing and maintaining oral health-promoting school programs. This information can assist decision-makers in adopting these programs on a larger scale and effectively addressing oral diseases among children and adolescents. PROTOCOL REGISTRATION: CRD42022363743.

The economic burden of Chagas disease: A systematic review.

BACKGROUND: Chagas disease (CD) is a neglected disease affecting millions worldwide, yet little is known about its economic burden. This systematic review is part of RAISE project, a broader study that aims to estimate the global prevalence, mortality, and health and economic burden attributable to chronic CD and Chronic Chagas cardiomyopathy. The objective of this study was to assess the main costs associated with the treatment of CD in both endemic and non-endemic countries. METHODS: An electronic search of the Medline, Lilacs, and Embase databases was conducted until 31st, 2022, to identify and select economic studies that evaluated treatment costs of CD. No restrictions on place or language were made. Complete or partial economic analyses were included. RESULTS: Fifteen studies were included, with two-thirds referring to endemic countries. The most commonly investigated cost components were inpatient care, exams, surgeries, consultation, drugs, and pacemakers. However, significant heterogeneity in the estimation methods and presentation of data was observed, highlighting the absence of standardization in the measurement methods and cost components. The most common component analyzed using the same metric was hospitalization. The mean annual hospital cost per patient ranges from $25.47 purchasing power parity US dollars (PPP-USD) to $18,823.74 PPP-USD, and the median value was $324.44 PPP-USD. The lifetime hospital cost per patient varies from $209,44 PPP-USD for general care to $14,351.68 PPP-USD for patients with heart failure. DISCUSSION: Despite the limitations of the included studies, this study is the first systematic review of the costs of CD treatment. The findings underscore the importance of standardizing the measurement methods and cost components for estimating the economic burden of CD and improving the comparability of cost components magnitude and cost composition analysis. Finally, assessing the economic burden is essential for public policies designed to eliminate CD, given the continued neglect of this disease.

Estimation of Health-Related Quality of Life Losses Owing to a Technological Disaster in Brazil Using EQ-5D-3L: A Cross-Sectional Study.

OBJECTIVES: In 2015, a dam collapsed at Samarco iron ore mine in the municipality of Mariana, Brazil, and contaminated more than 600 km of watercourses and destroyed almost 1600 acres of vegetation. Nineteen people died and more than 600 families lost their homes. This study aimed to estimate health-related quality of life (HRQoL) losses owing to this disaster. METHODS: We collected data from a probabilistic sample of 459 individuals aged 15 years or older. Household face-to-face interviews were conducted in December 2018. Pre-event data were not available for this population, so respondents were asked to evaluate at present and in retrospect their health status using EQ-5D-3L. The Minas Gerais societal value sets for EQ-5D-3L health preferences, estimated in 2011, were used to calculate utility losses. The health loss estimation from EQ-5D will form the basis for the calculation of compensation payments for the victims. RESULTS: Approximately 74% of the study population suffered some HRQoL loss. On average, EQ-5D index values decreased from 0.95 to 0.76. The greatest effects were observed for the anxiety/depression dimension, followed by pain/discomfort. Before the tragedy, the proportion of individuals with severe anxiety/depression and pain/discomfort was equal to 1% rising to 23% and 11%, respectively. CONCLUSIONS: Catastrophic losses owing to the Samarco disaster were found. The EQ-5D-3L instrument showed feasibility and sensitiveness to measure HRQoL losses owing to a negative health shock in a low-income Brazilian population.

Health-related vulnerability to climate extremes in homoclimatic zones of Amazonia and Northeast region of Brazil.

Amazonia and the Northeast region of Brazil exhibit the highest levels of climate vulnerability in the country. While Amazonia is characterized by an extremely hot and humid climate and hosts the world largest rainforest, the Northeast is home to sharp climatic contrasts, ranging from rainy areas along the coast to semiarid regions that are often affected by droughts. Both regions are subject to extremely high temperatures and are susceptible to many tropical diseases. This study develops a multidimensional Extreme Climate Vulnerability Index (ECVI) for Brazilian Amazonia and the Northeast region based on the Alkire-Foster method. Vulnerability is defined by three components, encompassing exposure (proxied by seven climate extreme indicators), susceptibility (proxied by sociodemographic indicators), and adaptive capacity (proxied by sanitation conditions, urbanization rate, and healthcare provision). In addition to the estimated vulnerability levels and intensity, we break down the ECVI by indicators, dimensions, and regions, in order to explore how the incidence levels of climate-sensitive infectious and parasitic diseases correlate with regional vulnerability. We use the Grade of Membership method to reclassify the mesoregions into homoclimatic zones based on extreme climatic events, so climate and population/health data can be analyzed at comparable resolutions. We find two homoclimatic zones: Extreme Rain (ER) and Extreme Drought and High Temperature (ED-HT). Vulnerability is higher in the ED-HT areas than in the ER. The contribution of each dimension to overall vulnerability levels varies by homoclimatic zone. In the ER zone, adaptive capacity (39%) prevails as the main driver of vulnerability among the three dimensions, in contrast with the approximately even dimensional contribution in the ED-HT. When we compare areas by disease incidence levels, exposure emerges as the most influential dimension. Our results suggest that climate can exacerbate existing infrastructure deficiencies and socioeconomic conditions that are correlated with tropical disease incidence in impoverished areas.

The COVID-19 pandemic in Brazil: analysis of supply and demand of hospital and ICU beds and mechanical ventilators under different scenarios. / Pandemia por COVID-19 no Brasil: análise da demanda e da oferta de leitos hospitalares e equipamentos de ventilação assistida segundo diferentes cenários.

This study aims to analyze the pressure on the Brazilian health system from the additional demand created by COVID-19. The authors performed a series of simulations to estimate the demand for hospital beds (health micro-regions) as well as to ICU beds, and mechanical ventilators (health macro-regions) under different scenarios of intensity (infection rates equivalent to 0.01, 0.1, and 1 case por 100 inhabitants) and time horizons (1, 3, and 6 months). The results reveal a critical situation in the system for meeting this potential demand, with numerous health micro-regions and macro-regions operating beyond their capacity, compromising the care for patients, especially those with more severe symptoms. The study presents three relevant messages. First, it is necessary to slow the spread of COVID-19 in the Brazilian population, allowing more time for the reorganization of the supply and relieve the pressure on the health system. Second, the expansion of the number of available beds will be the key. Even if the private sector helps offset the deficit, the combined supply from the two sectors (public and private) would be insufficient in various macro-regions. The construction of field hospitals is important, both in places with a history of "hospital deserts" and in those already pressured by demand. The third message involves the regionalized organization of health services, whose design may be adequate in situations of routine demand, but which suffer additional challenges during pandemics, especially if patients have to travel long distances to receive care.

O objetivo deste estudo é analisar a pressão sobre o sistema de saúde no Brasil decorrente da demanda adicional gerada pela COVID-19. Para tanto, foi realizado um conjunto de simulações para estimar a demanda de leitos gerais (microrregiões de saúde), leitos de UTI e equipamentos de ventilação assistida (macrorregiões de saúde) em diferentes cenários, para intensidade (taxas de infecção equivalentes a 0,01, 0,1 e 1 caso por 100 habitantes) e horizontes temporais (1, 3 e 6 meses). Os resultados evidenciam uma situação crítica do sistema para atender essa demanda potencial, uma vez que diversas microrregiões e macrorregiões de saúde operariam além de sua capacidade, comprometendo o atendimento a pacientes principalmente aqueles com sintomas mais severos. O estudo apresenta três mensagens relevantes. Em primeiro lugar, é necessário reduzir a velocidade de propagação da COVID-19 na população brasileira, permitindo um tempo maior para a reorganização da oferta e aliviando a pressão sobre o sistema de saúde. Segundo, é necessário expandir o número de leitos disponíveis. Ainda que o setor privado contribua para amortecer o déficit de demanda, a oferta conjunta dos dois setores não seria suficiente em várias macrorregiões. A construção de hospitais de campanha é importante, tanto em locais onde historicamente há vazios assistenciais como também naqueles onde já se observa uma pressão do lado da demanda. A terceira mensagem diz respeito à organização regionalizada dos serviços de saúde que, apesar de adequada em situações de demanda usual, em momentos de pandemia este desenho implica desafios adicionais, especialmente se a distância que o paciente tiver de percorrer for muito grande.

El objetivo de este estudio es analizar la presión sobre el sistema de salud brasileño, ocasionada por la demanda adicional de camas hospitalarias y equipos de ventilación mecánica, generada por el COVID-19. Para tal fin, se realizó un conjunto de simulaciones, con el fin de estimar la demanda de camas generales (microrregiones de salud), camas de UTI y equipamientos de ventilación asistida (macrorregiones de salud) en diferentes escenarios, según la intensidad (tasas de infección equivalentes a 0,01, 0,1 y 1 caso por 100 habitantes) y horizontes temporales (1, 3 y 6 meses). Los resultados evidencian una situación crítica del sistema para atender esa demanda potencial, ya que diversas microrregiones y macrorregiones de salud operarían más allá de su capacidad, comprometiendo la atención a pacientes principalmente aquellos con los síntomas más graves. El estudio presenta tres mensajes relevantes. En primer lugar, es necesario reducir la velocidad de propagación del COVID-19 en la población brasileña, permitiendo un tiempo mayor para la reorganización de la oferta y aliviando la presión sobre el sistema de salud. En segundo lugar, es necesario expandir el número de camas disponibles. A pesar de que el sector privado contribuya a amortiguar el déficit de demanda, la oferta conjunta de los dos sectores no sería suficiente en varias macrorregiones. La construcción de hospitales de campaña es importante, tanto en lugares donde históricamente existen lagunas asistenciales, como también en aquellos donde ya se observa una presión por parte de la demanda. El tercer mensaje se refiere a la organización por regiones de los servicios de salud que, a pesar de ser adecuada en situaciones de demanda habitual, en momentos de pandemia, este diseño implica desafíos adicionales, especialmente si la distancia que el paciente tuviera que recorrer fuera muy lejana.

The Price of Substitute Technologies.

BACKGROUND: Only a small share of new drugs is truly innovative; 85% to 90% of all new health technologies have little or no advantage over existing therapeutic alternatives. Health economic evaluations can be used to induce acceptable prices for new technologies through threshold pricing. OBJECTIVE: This work discusses a cost-effectiveness threshold (λ) to be applied to the price regulation of substitute technologies. METHODS: Considering that substitute technologies add only small marginal benefits in terms of innovation or ethical considerations to the system, it does not make sense to allow a loss of efficiency to list them. It has been postulated that the threshold calculated from opportunity costs (κ) represents its maximum possible value and that there must be a threshold (ß) that maximizes consumer surplus. For a substitute technology to be listed, the cost of treatment associated with it must be lower than the cost of treatment of the incumbent technology added to the difference in effectiveness priced at the threshold. RESULTS: There is no reason for us to believe that the oligopolistic pharmaceutical market is currently charging prices at the cost of production. That way, the cost-effectiveness ratio of the incumbent technology, when lower than κ, is shown through a deductive process to be a plausible estimate for λ that fulfills the objective of maximizing consumer benefit, granting producers a part of the combined surplus to stimulate research and development; that is, it would be between ß and κ. CONCLUSION: In conclusion, the price of substitute technologies should be limited by the cost-effectiveness ratio of the incumbent technology.

Enough with the madness: a systematic review and meta-analysis of hydroxychloroquine for COVID-19 / Chega de loucura: uma revisão sistemática e metanálise de hidroxicloroquina para COVID-19

Objective: Because of preliminary results from in vitro studies, ydroxychloroquine (HCQ) and chloroquine (CQ) have been proposed as possible treatments for COVID-19, but the clinical evidence is discordant. This study aims to evaluate the safety and efficacy of CQ and HCQ for the treatment of COVID-19. Methods: A systematic review with meta-analysis was performed. An electronic search was conducted in four databases for randomized controlled trials that compared HCQ or CQ with standard-of-care. A complementary search was performed. A quantitative synthesis of clinical outcomes was performed using the inverse variance method adjusting for a random-effects model. Results: In total, 16 studies were included. The meta-analysis found no significant difference between intervention and control groups in terms of mortality at the most extended follow-up (RR = 1.09, CI95% = 0.99-1.19, p-value = 0.08), patients with negative PCR results (RR = 0.99, CI95% = 0.89-1.10, p-value = 0.86), or serious adverse events (RR = 2.21, CI95% = 0.89-5.47, p-value = 0.09). HCQ was associated with an increased risk of adverse events (RR = 2.28, CI95% = 1.36-2.83, p-value < 0.01). The quality of evidence varied from very low to high. Conclusion: There is no evidence that HCQ reduces the risk of death or improves cure rates in patients with COVID-19, but it might be associated with an increased risk of adverse events

Objetivo: Devido aos resultados preliminares de estudos in vitro, a hidroxicloroquina (HCQ) e a cloroquina (CQ) foram propostas como possíveis tratamentos para a COVID-19, mas as evidências clínicas são discordantes. Este estudo tem como objetivo avaliar a segurança e a eficácia da CQ e HCQ no tratamento da COVID-19. Métodos: Foi realizada uma revisão sistemática com metanálise. Uma busca eletrônica foi realizada em quatro bancos de dados por ensaios clínicos randomizados que compararam a HCQ ou CQ com o tratamento-padrão. Uma busca complementar foi realizada. Uma síntese quantitativa dos resultados foi realizada usando o método de variância inversa para um modelo de efeitos aleatórios. Resultados: No total, 16 estudos foram incluídos. A metanálise não encontrou nenhuma diferença significativa entre os grupos de intervenção e controle em termos de mortalidade no acompanhamento mais longo (RR = 1,09, IC95% = 0,99-1,19, valor-p = 0,08), pacientes com resultados de PCR negativos (RR = 0,99, IC95% = 0,89-1,10, valor-p = 0,86) ou eventos adversos graves (RR = 2,21, IC95% = 0,89-5,47, valor-p = 0,09). HCQ foi associada a um risco aumentado de eventos adversos (RR = 2,28, IC95% = 1,36-2,83, valor-p < 0,01). A qualidade da evidência variou de muito baixa a alta. Conclusão: Não há evidências de que a HCQ reduza o risco de morte ou aumente a taxa de cura em pacientes com COVID-19, mas pode estar associada a um risco aumentado de eventos adversos

Rotational thromboelastometry in the perioperative period of cardiac surgeries: cost-effectiveness analysis and budget impact / Tromboelastometria rotacional no período perioperatório de cirurgias cardíacas: custo-efetividade e impacto orçamentário

Objective: The transfusion of blood components and blood products in cardiac surgery patients can be guided by protocols based on standard laboratory tests and/or clinical decisions (Standardof-Care, SOC) or viscoelastic haemostatic assays (VHA). The aim of this study is to evaluate the cost-effectiveness and budget impact of VHAs compared to SOC. Methods: A decision tree model was built in TreeAge Pro® 2009. Costs and benefits were taken from the medical literature. The costeffectiveness was evaluated in a base-case scenario and a worst-case scenario, considering low costs of adverse events. The budget impact was evaluated from data taken from Datasus. Cost data were measured in 2019 USD and outcomes were measured in QALYs. Results: VHAs were considered dominant in the base-case scenario and very cost-effective in the worst-case scenario (ICER = $ 1,083.21 USD/QALY). The budget impact analysis varied from a cost-saving result in the base-case scenario to a reasonable increase in cost in the worst-case scenario. Since the total market share of the technology is unlikely, a reasonable estimative for the base-case scenario and the worst-case scenario are about -$275 million USD and $132 million USD, respectively. Conclusion: We conclude that the VHAs are cost-effective and should be recommended for the use in the perioperative period of cardiac surgeries, especially for patients with a high risk of hemorrhage or coagulation problems.

Objetivo: A transfusão de sangue, hemocomponentes e produtos sanguíneos em pacientes submetidos a cirurgia cardíaca pode ser guiada por protocolos baseados em testes laboratoriais padrão e/ou decisão clínica (Standard-of-Care, SOC) ou testes viscoelásticos (TVEs). O objetivo deste estudo é avaliar o custo-efetividade e o impacto orçamentário dos TVEs em comparação com o SOC. Métodos: Um modelo de árvore de decisão foi construído em TreeAge Pro® 2009. Os parâmetros de custos e benefícios foram obtidos da literatura médica. A relação custo-efetividade foi avaliada em um cenário-base e no pior cenário, considerando baixos custos de eventos adversos. O impacto orçamentário foi avaliado a partir de dados extraídos do Datasus. Os custos foram avaliados em USD 2019 e os desfechos em AVAQs. Resultados: Os TVEs foram considerados dominantes no cenário-base e muito custo-efetivos no pior cenário avaliado (RCEI = 1.083,21 USD/QALY). A análise de impacto orçamentário variou de um resultado de economia de custos no cenário-base a um aumento razoável no custo no pior cenário. Como a hipótese de que a tecnologia será adotada para toda a demanda do mercado é improvável, estimativas razoáveis para o cenário-base e o pior cenário são de aproximadamente -275 milhões de USD e 132 milhões de USD, respectivamente. Conclusão: Concluímos que os VHAs são econômicos e devem ser recomendados para uso no período perioperatório de cirurgias cardíacas, principalmente para pacientes com alto risco de problemas de hemorragia ou coagulação.

Pandemia por COVID-19 no Brasil: análise da demanda e da oferta de leitos hospitalares e equipamentos de ventilação assistida segundo diferentes cenários / Pandemia por COVID-19 en Brasil: análisis de la demanda y oferta de camas hospitalarias, así como equipamientos de ventilación asistida, según diferentes escenarios / The COVID-19 pandemic in Brazil: analysis of supply and demand of hospital and ICU beds and mechanical ventilators under different scenarios

O objetivo deste estudo é analisar a pressão sobre o sistema de saúde no Brasil decorrente da demanda adicional gerada pela COVID-19. Para tanto, foi realizado um conjunto de simulações para estimar a demanda de leitos gerais (microrregiões de saúde), leitos de UTI e equipamentos de ventilação assistida (macrorregiões de saúde) em diferentes cenários, para intensidade (taxas de infecção equivalentes a 0,01, 0,1 e 1 caso por 100 habitantes) e horizontes temporais (1, 3 e 6 meses). Os resultados evidenciam uma situação crítica do sistema para atender essa demanda potencial, uma vez que diversas microrregiões e macrorregiões de saúde operariam além de sua capacidade, comprometendo o atendimento a pacientes principalmente aqueles com sintomas mais severos. O estudo apresenta três mensagens relevantes. Em primeiro lugar, é necessário reduzir a velocidade de propagação da COVID-19 na população brasileira, permitindo um tempo maior para a reorganização da oferta e aliviando a pressão sobre o sistema de saúde. Segundo, é necessário expandir o número de leitos disponíveis. Ainda que o setor privado contribua para amortecer o déficit de demanda, a oferta conjunta dos dois setores não seria suficiente em várias macrorregiões. A construção de hospitais de campanha é importante, tanto em locais onde historicamente há vazios assistenciais como também naqueles onde já se observa uma pressão do lado da demanda. A terceira mensagem diz respeito à organização regionalizada dos serviços de saúde que, apesar de adequada em situações de demanda usual, em momentos de pandemia este desenho implica desafios adicionais, especialmente se a distância que o paciente tiver de percorrer for muito grande.

El objetivo de este estudio es analizar la presión sobre el sistema de salud brasileño, ocasionada por la demanda adicional de camas hospitalarias y equipos de ventilación mecánica, generada por el COVID-19. Para tal fin, se realizó un conjunto de simulaciones, con el fin de estimar la demanda de camas generales (microrregiones de salud), camas de UTI y equipamientos de ventilación asistida (macrorregiones de salud) en diferentes escenarios, según la intensidad (tasas de infección equivalentes a 0,01, 0,1 y 1 caso por 100 habitantes) y horizontes temporales (1, 3 y 6 meses). Los resultados evidencian una situación crítica del sistema para atender esa demanda potencial, ya que diversas microrregiones y macrorregiones de salud operarían más allá de su capacidad, comprometiendo la atención a pacientes principalmente aquellos con los síntomas más graves. El estudio presenta tres mensajes relevantes. En primer lugar, es necesario reducir la velocidad de propagación del COVID-19 en la población brasileña, permitiendo un tiempo mayor para la reorganización de la oferta y aliviando la presión sobre el sistema de salud. En segundo lugar, es necesario expandir el número de camas disponibles. A pesar de que el sector privado contribuya a amortiguar el déficit de demanda, la oferta conjunta de los dos sectores no sería suficiente en varias macrorregiones. La construcción de hospitales de campaña es importante, tanto en lugares donde históricamente existen lagunas asistenciales, como también en aquellos donde ya se observa una presión por parte de la demanda. El tercer mensaje se refiere a la organización por regiones de los servicios de salud que, a pesar de ser adecuada en situaciones de demanda habitual, en momentos de pandemia, este diseño implica desafíos adicionales, especialmente si la distancia que el paciente tuviera que recorrer fuera muy lejana.

This study aims to analyze the pressure on the Brazilian health system from the additional demand created by COVID-19. The authors performed a series of simulations to estimate the demand for hospital beds (health micro-regions) as well as to ICU beds, and mechanical ventilators (health macro-regions) under different scenarios of intensity (infection rates equivalent to 0.01, 0.1, and 1 case por 100 inhabitants) and time horizons (1, 3, and 6 months). The results reveal a critical situation in the system for meeting this potential demand, with numerous health micro-regions and macro-regions operating beyond their capacity, compromising the care for patients, especially those with more severe symptoms. The study presents three relevant messages. First, it is necessary to slow the spread of COVID-19 in the Brazilian population, allowing more time for the reorganization of the supply and relieve the pressure on the health system. Second, the expansion of the number of available beds will be the key. Even if the private sector helps offset the deficit, the combined supply from the two sectors (public and private) would be insufficient in various macro-regions. The construction of field hospitals is important, both in places with a history of "hospital deserts" and in those already pressured by demand. The third message involves the regionalized organization of health services, whose design may be adequate in situations of routine demand, but which suffer additional challenges during pandemics, especially if patients have to travel long distances to receive care.

Silicone tape versus micropore tape to prevent medical adhesive-related skin injuries: systematic review and meta-analysis / Fita de silicone versus fita microporosa para prevenção de lesão cutânea relacionada a adesivos médicos: revisão sistemática e metanálise

Objective: This study aims to compare the efficacy and safety of silicone tapes compared to microporous tapes in patients with fragile skin. Methods: A systematic review of the scientific literature was carried out. Clinical trials that compared silicone tape for medical use with the microporous tape in preterm newborns, newborns, children, elders, or people with increased risk of MARSI were included. This report followed the principles of the PRISMA statement. Results: Three randomized controlled trials were included. The silicone tape was associated with fewer injuries (RR = 0.53; p-value = 0.03), but no difference was found in terms of prevention of moderate or severe injuries (RR = 0.25; p-value = 0.20). Silicone tapes produce significantly less edema/erythema response than microporous tapes in children (MD = -0.42; p-value < 0.0001). The quality of evidence was considered very low. Conclusion: The evidence suggests that silicone tapes may be gentler to patients' skin than microporous tapes. However, no study reported data on the outcomes of interest. The studies have small samples, a short time horizon, and the quality of evidence was considered very low. There is insufficient information to allow the recommendation of silicone tapes to prevent skin injuries compared to microporous tapes.

Objetivo: O objetivo deste estudo é avaliar a eficácia e a segurança das fitas de silicone comparadas às fitas microporosas em pacientes com pele frágil. Métodos: Uma revisão sistemática da literatura foi conduzida. Ensaios clínicos que compararam a fita de silicone para uso médico com a fita microporosa em pacientes prematuros, neonatos, crianças, idosos ou pessoas com risco aumentado de lesão por adesivos médicos foram incluídos. Esse relato seguiu os princípios do relatório PRISMA. Resultados: Três ensaios clínicos randomizados foram incluídos. As fitas de silicone foram associadas a menor risco de lesões (RR = 0,53; valor-p = 0,03), mas não foi observada diferença em termos de lesões moderadas ou graves (RR = 0,25; valor-p = 0,20), e produziram significativamente menos edema/eritema que fitas microporosas em crianças (MD = -0,42; valor-p < 0,0001). A qualidade da evidência foi considerada baixa. Conclusão: A evidência sugere que as fitas de silicone são mais gentis à pele dos pacientes que as fitas microporosas. No entanto, nenhum estudo incluído reportou dados sobre os desfechos de interesse. Os estudos tinham amostras pequenas, horizonte temporal curto e qualidade de evidência muito baixa. A informação existente é insuficiente para possibilitar a recomendação das fitas de silicone para prevenção de lesões cutâneas em comparação com as fitas microporosas.

Colangiopancreatografia retrógrada endoscópica para cálculos no ducto biliar comum: overview de revisões sistemáticas e estudos econômicos / Endoscopic retrograde cholangiopancreatography for common bile duct calculi: overview of systematic reviews and economic assessments

Objetivo: Avaliar a eficácia, segurança e custo-efetividade da colangiopancreatografia retrógrada endoscópica (CPRE) comparada à exploração laparoscópica do ducto biliar comum (ELDBC) para coledocolitíase. Métodos: Foi realizada uma busca eletrônica nas bases de dados Medline, The Cochrane Library, Lilacs e Center for Reviews and Dissemination por revisões sistemáticas e estudos econômicos que reportassem dados sobre a comparação entre a CPRE e a ELDBC em pacientes com coledocolitíase. Uma busca complementar foi realizada nas referências dos estudos incluídos, periódicos, resumos de congresso e Google Acadêmico. A seleção foi realizada por dois pesquisadores independentes. Além da síntese qualitativa, uma ressíntese quantitativa para os desfechos primários foi conduzida em Review Manager® 5.3 utilizando um modelo de efeitos randômicos. Resultados: Foram incluídos 15 estudos (9 revisões sistemáticas e 6 estudos econômicos). Não foi demonstrada diferença estatisticamente significativa entre a colecistectomia laparoscópica (CL)+CPRE e a CL+ELDBC em termos de remoção dos cálculos do colédoco (88,5% vs. 92,8%; RR = 0,97, valor-p = 0,08; N = 1.881), morbidade pós-operatória (14,1% vs. 13,8%; RR = 0,98, valor-p = 0,88; N = 1.469), mortalidade (0,8% vs. 0,2%; RR = 2,13, valor-p = 0,33; N = 1.471), cálculos retidos (7,3% vs. 5,8%; RR = 1,17, valor-p = 0,40; N = 1.731), conversão para outros procedimentos (8,7% vs. 6,7%; RR = 1,20, valor-p = 0,55; N = 1.287), duração do procedimento (MD = 10,91, valor-p = 0,61; N = 717) ou tempo de hospitalização (MD = 1,31, valor-p = 0,10; N = 757). A literatura de custo-efetividade é dividida, com alguns estudos favorecendo a CL+CPRE e outros, a CL+ELDBC. Conclusão: Não é possível concluir sobre a superioridade da ELDBC sobre a CPRE ou vice-versa para a remoção de cálculos no colédoco.

Objective: To evaluate the efficacy, safety and cost-effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) compared to laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis. Methods: An electronic search was conducted in the Medline, The Cochrane Library, Lilacs and Center for Reviews and Dissemination databases for systematic reviews and economic studies that reported data on the comparison between ERCP and LCBDE in patients with choledocholithiasis. A complementary search was conducted on references of included studies, journals, conference abstracts and Google Scholar. The selection was performed by two independent reviewers. In addition to the qualitative synthesis, a quantitative re-synthesis for primary outcomes was conducted in Review Manager® 5.3 using a random effects model. Results: Fifteen studies (9 systematic reviews and 6 economic studies) were included. There was no statistically significant difference between laparoscopic cholecystectomy (LC)+ERCP and LC+LCBDE in terms of removal of choledochal stones (88.5% vs. 92.8%, RR = 0.97, p-value = 0.08; N = 1,881), morbidity (14.1% vs. 13.8%, RR = 0.98, p-value = 0.88; N = 1,469), mortality (0.8% vs. 0,2%; RR = 2.13, p-value = 0.33, N = 1,471), retained stones (7.3% vs. 5.8%, RR = 1.17, p-value = 0.40; N = 1,731), conversion to other procedures (8.7% vs. 6.7%, RR = 1.20, p-value = 0.55, N = 1,287), duration of the procedure (MD = 10.91, p = 0.61, N = 717) or hospital stay (MD = 1.31, p-value = 0.10, N = 757). The cost-effectiveness literature is divided. Some studies favor LC+ERCP and others LC+LCBDE. Conclusion: It is not possible to conclude on the superiority of the LCBDE on ERCP or vice-versa for choledocholithiasis

What matters most? Evidence-based findings of health dimensions affecting the societal preferences for EQ-5D health states.

This study analyzes how different health dimensions defined by the EQ-5D-3L instrument affect average individual preferences for health states. This analysis is an important benchmark for the incorporation of health technologies as it takes into consideration Brazilian population preferences in health resource allocation decisions. The EQ-5D instrument defines health in terms of five dimensions (mobility, daily activities, self-care activities, pain/discomfort, and anxiety/depression) each divided into three levels of severity. Data came from a valuation study with 3,362 literate individuals aged between 18 and 64 living in urban areas of Minas Gerais State, Brazil. The main results reveal that health utility decreases as the level of severity increases. With regard to health issues, mobility stands out as the most important EQ-5D dimension. Independently of severity levels of the other EQ-5D-3L dimensions, the highest decrements in utilities are associated with severe mobility problems.

What matters most?: evidence-based findings of health dimensions affecting the societal preferences for EQ-5D health states / O que importa mais?: evidências empíricas das dimensões que afetam as preferências sociais para estados de saúde do EQ-5D / ¿Qué es lo que más importa?: evidencias empíricas sobre las dimensiones que afectan a las preferencias sociales por los estados de salud en EQ-5D

This study analyzes how different health dimensions defined by the EQ-5D-3L instrument affect average individual preferences for health states. This analysis is an important benchmark for the incorporation of health technologies as it takes into consideration Brazilian population preferences in health resource allocation decisions. The EQ-5D instrument defines health in terms of five dimensions (mobility, daily activities, self-care activities, pain/discomfort, and anxiety/depression) each divided into three levels of severity. Data came from a valuation study with 3,362 literate individuals aged between 18 and 64 living in urban areas of Minas Gerais State, Brazil. The main results reveal that health utility decreases as the level of severity increases. With regard to health issues, mobility stands out as the most important EQ-5D dimension. Independently of severity levels of the other EQ-5D-3L dimensions, the highest decrements in utilities are associated with severe mobility problems.

Este estudo analisa como as diferentes dimensões dos estados de saúde definidas pelo instrumento EQ-5D-3L afetam, em média, as preferências dos indivíduos por estados de saúde. Essa análise é importante para balizar a incorporação de tecnologias em saúde uma vez que viabiliza considerar as preferências da população brasileira na decisão de alocação de recursos em saúde. O EQ-5D-3L define a saúde em cinco dimensões (mobilidade, atividades habituais, auto-cuidado, dor/desconforto e ansiedade/depressão) contendo três níveis de severidade. Os dados são provenientes de uma pesquisa inédita no Brasil que entrevistou 3.362 pessoas com idade entre 18 e 64 anos vivendo em áreas urbanas de Minas Gerais. Os principais resultados mostram que o decremento na utilidade dos indivíduos é crescente com o nível de severidade. No que se refere às dimensões de saúde, a mobilidade se destaca como a mais importante. Independentemente dos níveis de severidade das demais dimensões do EQ-5D, os maiores decrementos nas utilidades estão associados ao problema de mobilidade severa.

Este estudio analiza cómo las diferentes dimensiones de la salud, definidas por el instrumento EQ-5D-3L, afectan, en promedio, las preferencias individuales por los estados de salud. Este análisis es un punto de referencia para la incorporación de tecnologías en salud, ya que hace posible considerar las preferencias de la población brasileña en las decisiones sobre la asignación de recursos de salud. El EQ-5D define la salud en cinco dimensiones (movilidad, actividades habituales, cuidado personal, dolor/malestar y ansiedad/depresión) con tres niveles de severidad. Los datos provienen de una investigación inédita en Brasil, que entrevistó a 3.362 personas entre 18 y 64 años y que viven en zonas urbanas de Minas Gerais. Los principales resultados muestran que la disminución en la utilidad de los individuos aumenta con el nivel de severidad. Con respecto a las dimensiones de salud, la movilidad se destaca como la más importante. Independientemente de los niveles de severidad de las otras dimensiones, los mayores decrementos en la utilidad están asociados con graves problemas de movilidad.

[Social inequality in health and the utilization of health services among the elderly in Latin America]. / Desigualdades sociais em saúde e na utilização dos serviços de saúde entre os idosos na América Latina.

OBJECTIVE: To learn if there is social inequality in health and in the utilization of health services among the elderly in six cities of Latin America: Buenos Aires, Argentina; São Paulo, Brazil; Santiago, Chile; Havana, Cuba; Mexico City, Mexico; and Montevideo, Uruguay. METHODS: This study used data from a project called Health, Well-being, and Aging in Latin America and the Caribbean (known as the "SABE project"). To investigate the presence of social inequality in health an ordinal probit model was used, with health status indicated by the following dependent variables: activities of daily living, instrumental activities of daily living, physical mobility, and self-rated health. To measure social inequality in the utilization of health services two characteristics were assessed: one for outpatient medical services (whether or not individuals received outpatient care, and how many times), and one for hospital admissions (whether or not individuals were hospitalized). For outpatient services, we estimated a negative binomial hurdle model, and for hospital admissions, a logit model was constructed. RESULTS: Our main results suggest the presence of social inequality in health in all the cities, with better-off socioeconomic groups having better health. The difference in health was less marked in Havana, Buenos Aires, and Montevideo, and it was more pronounced in São Paulo and Mexico City. With respect to the utilization of health services we found inequalities in the use of outpatient services in Santiago, Mexico City, and São Paulo. In Santiago and Mexico City, more schooling was associated with a higher number of expected outpatient medical visits; however, the opposite was found in São Paulo. For hospital admissions, inequality was found only in São Paulo, with individuals with more years of schooling being much more likely to be hospitalized. CONCLUSION: To a certain extent, our results reflect the socioeconomic and demographic characteristics of the countries in which each of the six cities is located. The cities in the countries with the worst social indicators (high income inequality and low human development index) tended to have the greatest inequalities in health and in the utilization of health services.