Expanding comprehensive pregnancy care for Emergency Medicaid recipients: a cost-effectiveness analysis.

BACKGROUND: Emergency Medicaid is a restricted benefits program for individuals who have low-income status and who are immigrants. OBJECTIVE: This study aimed to compare the cost-effectiveness of 2 strategies of pregnancy coverage for Emergency Medicaid recipients: the federal minimum of covering the delivery only vs extended coverage to 60 days after delivery. STUDY DESIGN: A decision analytical Markov model was developed to evaluate the outcomes and costs of these policies, and the results in a theoretical cohort of 100,000 postpartum Emergency Medicaid recipients were considered. The payor perspective was adopted. Health outcomes and cost-effectiveness over a 1- and 3-year time horizon were investigated. All probabilities, utilities, and costs were obtained from the literature. Our primary outcome was the incremental cost-effectiveness ratio of the competing strategies. RESULTS: Extending Emergency Medicaid to 60 days after delivery was determined to be a cost-saving strategy. Providing postpartum and contraceptive care resulted in 33,900 additional people receiving effective contraception in the first year and prevented 7290 additional unintended pregnancies. Over 1 year, it resulted in a gain of 1566 quality-adjusted life year at a cost of $10,903 per quality-adjusted life year. By 3 years of policy change, greater improvements were observed in all outcomes, and the expansion of Emergency Medicaid became cost saving and the dominant strategy. CONCLUSION: The inclusion of postpartum care and contraception for immigrant women who have low-income status resulted in lower costs and improved health outcomes.

How CPC+ supported patient care during the COVID-19 pandemic: Lessons for alternative payment models.

BACKGROUND: A growing literature documents how primary care practices adapted to the COVID-19 pandemic. We examine a topic that has received less attention-how participants in an advanced alternative payment model perceive the model influenced their ability to meet patients' care needs during the pandemic. METHODS: Analysis of closed- and open-ended questions from a 2021 survey of 2496 practices participating in the Comprehensive Primary Care Plus (CPC+) model (92% response rate) and a 2021 survey of 993 randomly selected primary care physicians from these practices (55% response rate). Both surveys asked whether respondents agreed or disagreed that they or their practice was "better positioned to meet patients' care needs during the coronavirus pandemic" because of participation in CPC+. Both also included an open-ended question about CPC+'s effects. RESULTS: Half of practices and one-third of physicians agreed or strongly agreed that participating in CPC+ better positioned them to meet patients' care needs during the pandemic. One in 10 practices and 2 in 10 physicians, disagreed or strongly disagreed, while 4 in 10 practices and slightly more than half of physicians neither agreed nor disagreed (or, for physicians, didn't know). The most commonly identified CPC+ activities that facilitated meeting patient care needs related to practices' work on care management (e.g., risk stratification), access (e.g., telehealth), payment outside of fee-for-service (FFS), and staffing (e.g., supporting care managers). CONCLUSIONS: Most CPC+ practices and physicians were positive or neutral about participating in CPC+ in the context of COVID-19, indicating more benefit than risk to payment alternatives to FFS.

Surgical Treatment of Carotid-cavernous Fistula Performed through the Brazilian Unified Health System

Introduction The carotid-cavernous fistula (CCF) is an abnormal communication between the arterial carotid system and the cavernous sinus. In most cases, spontaneous fistulas are due to the rupture of intracavernous carotid artery aneurisms. Traumatic fistulas occur in 0.2% of head injuries, and 75% of all CCFs are caused by automobile accidents or penetrating traumas. Objective To identify the data regarding the number of annual procedures, hospital expenses, length of hospital stay, and the number of deaths of patients admitted by the Brazilian Unified Health System (SUS, in the Portuguese acronym), in the period between 2007 and 2017, using the surgical code of the surgical treatment for CCF. Methods The present was an ecological study whose data were obtained by consulting the database provided by the Department of Computer Sciences of the Brazilian Unified Health System (Datasus, in Portuguese). Results A total of 85 surgical procedures were performed for the treatment of CCFs from January 2007 to October 2017 through the Unified Health System (SUS, in Portuguese), and there was a reduction of 71.42% in this period. The annual incidence of patients undergoing this surgical treatment during the period observed remained low, with 1 case per 13,135,714 in 2007, and 1 case per 51,925,000 in 2017. Conclusion Despite the low annual incidence of the surgical treatment of CCFs performed by the SUS in Brazil in the period of 2007­2017, based on the data obtained on the average length of stay and expenditures in hospital services, it is necessary that we develop an adequate health planning.

Metodología para la estimación de costos directos de la atención integral para enfermedades no trasmisibles / Methodology for estimating total direct costs of comprehensive care for non-communicable diseases

RESUMEN Enfermedades como la diabetes mellitus (DM) y la hipertensión arterial (HTA) generan altos costos y son la causa más frecuente de mortalidad en la región de las Américas. En el caso del Perú, dados los cambios demográficos y epidemiológicos, y particularmente el aumento alarmante del sobrepeso y la obesidad, la carga de estas enfermedades tiene un crecimiento constante que implica la necesidad de asignar cada vez más recursos financieros a los servicios de salud. Los costos de la atención integral de estas enfermedades y sus complicaciones representan una carga económica que debe ser considerada por las instituciones de salud al elaborar su presupuesto. Con ese propósito, la Organización Panamericana de la Salud (OPS) ha apoyado al Ministerio de Salud (MINSA) con la realización de un estudio para la estimación de estos costos. En el presente artículo se describe esquemáticamente la metodología desarrollada para la estimación de los costos directos en la atención integral de la DM e HTA en los servicios de salud del MINSA y gobiernos regionales.

RESUMEN Diseases like diabetes mellitus (DM) and hypertension (HT) generate high costs and are the most common cause of mortality in the Americas. In the case of Peru, given demographic and epidemiological changes, particularly the alarming increase in overweight and obesity, the burden of these diseases is constantly increasing, resulting in the need to budget more financial resources to the health services. The total care costs of these diseases and their complications represent a financial burden that should be considered very carefully by health institutions when they draft their budgets. With this aim, the Pan American Health Organization has assisted the Ministry of Health (MINSA) with a study to estimate these costs. This article graphically describes the methodology developed to estimate the direct costs of comprehensive care for DM and HT to the health services of MINSA and regional governments.

Predicción del riesgo individual de alto coste sanitario para la identificación de pacientes crónicos complejos / Predicting individual risk of high healthcare cost to identify complex chronic patients

Objetivo: Construir y validar un modelo predictivo del riesgo de consumo de recursos sanitarios elevado, y evaluar su capacidad para identificar pacientes crónicos complejos. Métodos: Estudio transversal realizado en una organización sanitaria integrada sobre datos individuales de residentes 2 años consecutivos (88.795 personas). Variable dependiente: coste sanitario real superior al percentil 95 (P95), incluyendo todos los servicios de la organización sanitaria integrada y las recetas de farmacia. Variables predictoras: edad, sexo, morbilidad (según los clinical risk groups [CRG]) y datos seleccionados de utilización previa (uso de hospitalización, uso de medicación hospitalaria ambulatoria, gasto en recetas de farmacia). Análisis univariado descriptivo. Construcción de un modelo de regresión logística con nivel de confianza del 95%; análisis de validez mediante sensibilidad, especificidad, valor predictivo positivo (VPP) y área bajo la curva ROC (AUC). Resultados: Las personas con coste >P95 acumulan el 44% del coste sanitario total y se concentran en las categorías ACRG3 (aggregated CRG level 3) de enfermedades crónicas múltiples o graves. La carga de morbilidad aumenta con la edad. En el modelo, todas las variables fueron estadísticamente significativas excepto el sexo. Se obtuvo una sensibilidad del 48,4% (intervalo de confianza [IC]: 46,9%-49,8%), una especificidad del 97,2% (IC: 97,0%-97,3%), un VPP del 46,5% (IC: 45,0%-47,9%) y un AUC de 0,897 (IC: 0,892-0,902). Conclusiones: El consumo sanitario elevado se relaciona con la morbilidad crónica compleja. Un modelo basado en la edad, la morbilidad y la utilización previa es válido para predecir el riesgo de alto consumo, y así identificar la población diana de estrategias de atención proactiva para pacientes crónicos complejos (AU)

Objective: To develop a predictive model for the risk of high consumption of healthcare resources, and assess the ability of the model to identify complex chronic patients. Methods: A cross-sectional study was performed within a healthcare management organization by using individual data from 2 consecutive years (88,795 people). The dependent variable consisted of healthcare costs above the 95th percentile (P95), including all services provided by the organization and pharmaceutical consumption outside of the institution. The predictive variables were age, sex, morbidity-based on clinical risk groups (CRG)-and selected data from previous utilization (use of hospitalization, use of high-cost drugs in ambulatory care, pharmaceutical expenditure). A univariate descriptive analysis was performed. We constructed a logistic regression model with a 95% confidence level and analyzed sensitivity, specificity, positive predictive values (PPV), and the area under the ROC curve (AUC). Results: Individuals incurring costs >P95 accumulated 44% of total healthcare costs and were concentrated in ACRG3 (aggregated CRG level 3) categories related to multiple chronic diseases. All variables were statistically significant except for sex. The model had a sensitivity of 48.4% (CI: 46.9%-49.8%), specificity of 97.2% (CI: 97.0%-97.3%), PPV of 46.5% (CI: 45.0%-47.9%), and an AUC of 0.897 (CI: 0.892 to 0.902). Conclusions: High consumption of healthcare resources is associated with complex chronic morbidity. A model based on age, morbidity, and prior utilization is able to predict high-cost risk and identify a target population requiring proactive care (AU)

Características de las urgencias hospitalarias del Servicio Andalus de Salud durante 2012. A partir del Conjunto Mínimo Básico de Datos de urgencias / Case-mix of hospital emergencies in the Andalusian Health Service based on the 2012 Minimum Data Set. Spain

Fundamentos: La implantación de Diraya-Urgencias en los hospitales del Servicio Andaluz de Salud (SAS) y el desarrollo de un codificador automático propio ha permitido instaurar el Conjunto Mínimo Básico de Datos de Urgencias (CMBD-U). El objetivo de este artículo es describir la casuística de los servicios de urgencias hospitalarios utilizando las distintas dimensiones contenidas en el CMBD-U. Métodos: Utilizando el CMBD-U, se clasificaron 3.235.600 registros de urgencias hospitalarias de 2012 en categorías clínicas mediante el código CIE-9-MC proporcionado por el codificador automático. Se definieron reglas de validez para la explotación de los tiempos. Se realizó un análisis descriptivo obteniendo indicadores demográficos, cronológicos, tasas de hospitalización, retorno y exitus y tiempos asistenciales y de permanencia en urgencias. Resultados: Las mujeres generaron el 54,26% de las urgencias. Su edad media (39,98 años) superó a la de los hombres (37,61). El 21,49% fueron urgencias pediátricas. La máxima afluencia horaria fue de 10:00 a 13:00 y de 16:00 a 17:00. Los pacientes que no pasaron por observación (92,67%) permanecieron en urgencias 153 minutos de media. Más del 50% de las urgencias fueron generadas por lesiones e intoxicaciones, enfermedades respiratorias, osteomusculares y síntomas y signos. Entre los procesos asistenciales integrados se identificaron 79.191 casos de dolor torácico, 28.741 de insuficiencia cardiaca y 27.989 infecciones graves. Conclusiones: El CMBD-U permite analizar sistemáticamente las urgencias hospitalarias identificando la actividad desarrollada, la casuística atendida, los tiempos de respuesta asistencial y permanencia en urgencias y la calidad asistencial (AU)

Background: The implementation of digital health records in emergency departments (ED) in hospitals in theAndalusian Health Service and the development of an automatic encoder for this area have allowed us to establish a Minimum Data Set for Emergencies (MDS-ED). The aim of this article is to describe the casemix of hospital EDs using various dimensions contained in the MDS-ED. Methods: 3.235.600 hospital emergency records in 2012 were classified in clinical categories from the ICD-9-CM codes generated by the automatic encoder. Operating rules to obtain response time and length of stay were defined. A descriptive analysis was carried out to obtain demographic and chronological indicators as well as hospitalization, return and death rates and response time and length of stay in the EDs. Results:Women generated 54,26%of all occurrences and their average age (39,98 years) was higher than men’s (37,61). Paediatric emergencies accounted for 21,49% of the total. The peak hours were from 10:00 to 13:00 and from 16:00 to 17:00. Patients who did not undergo observation (92,67%) remained in the ED an average of 153 minutes. Injuries and poisoning, respiratory diseases, musculoskeletal diseases and symptoms and signs generated over 50% of all visits. 79.191 cases of chest pain, 28.741 episodes of heart failure and 27.989 episodes of serious infections were identified among the most relevant disorders. Conclusions: The MDS-ED makes it possible to address systematically the analysis of hospital emergencies by identifying the activity developed, the case-mix attended, the response times, the time spent in ED and the quality of the care (AU)

El Gasto Sanitario Público en Castilla-La Mancha, 1995-2008: comparación con el conjunto de las Comunidades Autónomas / Public Health Expenditure in Castilla-La Mancha, 1995-2008: compared with that of all the Autonomous Communities

Objetivo. Conocer el crecimiento y reparto del gasto público (GSP) entre 1995 y 2008 según sectores en la sanidad pública de Castilla-La Mancha y su comparación con el conjunto de las 17 comunidades autónomas (CCAA). Diseño. Estudio longitudinal retrospectivo. Participantes. Las 17 CCAA. Mediciones. Se determina el reparto del GSP castellano-manchego entre sus principales sectores y su crecimiento anual, comparándolo con la media autonómica. Se consideran también variables sociodemográficas como la renta y el envejecimiento poblacional. Resultados. Entre 1995 y 2008, el GSP per cápita castellano-manchego es un 7% inferior a la media autonómica, pero crece un 8% más. El gasto farmacéutico per cápita castellanomanchego es un 7% mayor que la media y su peso en el GSP es un 15% mayor. En Castilla- La Mancha, el incremento anual del gasto en atención hospitalaria es un 38% mayor que el de atención primaria (4,292% vs. 3,109%) y el hospital aumenta su participación en el GSP castellano-manchego un 0,079% anual, pero la atención primaria la reduce un 0,695%, un comportamiento similar al del conjunto autonómico. En términos per cápita, y en el promedio del periodo, el gasto hospitalario castellano-manchego es un 17% inferior a la media y el gasto en atención primaria un 6% superior. Conclusiones. Entre 1995 y 2008, y a pesar de exhibir un GSP per cápita inferior al promedio autonómico, Castilla-La Mancha mantiene su atención primaria con ventaja presupuestaria respecto al promedio autonómico y respecto al propio sector hospitalario castellano-manchego(AU)

Objective. To determine the growth and the distribution of public health expenditure (PHE) among health sectors in Castilla-La Mancha (CLM) from 1995 to 2008 and to compare them with those of all the 17 Autonomous Communities (ACs). Design. A longitudinal and retrospective study. Participants. The 17 ACs. Measurements. The distribution of the PHE among CLM health sectors and its annual growth are determined and compared to the AC average.. Demographic variables were also considered such as income level and population ageing. Results. Between 2002 and 2008, the CLM PHE per capita was 7% lower than the AC average but increased by 8%. The CLM pharmaceutical expenditure per capita was 7% higher than the AC average and its share in the PHE was 15% higher. The annual growth of hospital care expenditure in CLM was 38% higher than that of primary care (4.292% versus 3.109%) and the share of hospital care in the CLM PHE grew by 0.079% annually but the primary care decreased by 0.695%, similar to that of the ACs. On average, over this period, the hospital care expenditure per capita in CLM was 17% lower than the AC average but the per capita expenditure in primary care was 6% higher. Conclusions. Between 1995 and 2008, in spite of having a PHE per capita lower than the AC average, CLM maintained its primary care with a budgetary advantage compared to the AC average and to the CLM the hospital care expenditure(AU)

Atenção integral à saúde e diversidade sexual no Processo Transexualizador do SUS: avanços, impasses, desafios / Comprehensiveness and sexual diversity in the Brazilian norm in the process of health care for transsexuals: progress, dilemmas, challenges

A publicação da norma sobre o Processo Transexualizador no SUS, apesar de refletir importante conquista do segmento populacional de transexuais, denuncia a complexidade do avanço dos direitos sexuais no campo da Saúde Coletiva. O artigo tem por objetivo a consideração crítica dos avanços, impasses e desafios na instituição dessa política pública de saúde, discutindo a ambivalência no processo de construção da norma técnica. Resgata duas correntes paralelas de inserção do debate sobre saúde de transexuais no Ministério da Saúde: a judicialização e o compromisso com o programa de governo Brasil sem Homofobia. Sinaliza a qualidade parcial do avanço conquistado pela publicação da norma, já que estabeleceu, ao mesmo tempo em que afirmou o direito à saúde para transexuais, campos de exclusão para possíveis beneficiários das mesmas ações de saúde previstas, especificamente as travestis. A hipótese sustentada é a da incidência da heteronormatividade e do binarismo de gênero como fator limitador da democratização dessa política de saúde.

The Brazilian norm that establishes the conditions for the health care for transsexuals, despite reflecting important achievements of this population, reveals the complexity of the advancement of sexual rights in the field of public health. This paper aims to review the advances, challenges and dilemmas in the establishment of this public health policy, discussing the ambivalence in the process of building the technical standard. It releases two parallel chains of the inclusion of the debate about transgender health care in the Health Ministry: the judicialization and the committment with the government program "Brazil without Homophobia". It indicates the partial progress achieved by the publication of the standard, as it established exclusion areas for potential beneficiaries of the same set of health actions, specifically the transvestites, at the same time it stated the right to health care for transsexuals. The hypothesis sustained is that heteronormativity and the binary of gender work as limiting factors for the democratization of the health policy.

Partnered care in the Bahamas: A model of advanced healthcare delivery for developing countries / Cuidados mediante asociación en las bahamas: un modelo avanzado de prestación de servicios de salud Para los países en vías de desarrollo

OBJECTIVE: To assess the delivery of advanced specialized medical care using The Partnered Care Model as a means of providing affordable access to all, irrespective of ability to pay. DESIGN AND METHODS: A retrospective analysis of all persons presenting to a specialized, private, cardiac unit, The Bahamas Interventional Cardiology Center (BICC), over an 8.5-year period from March 1996 to September 2004 was conducted. The Bahamas Heart Center's Discounted Service System had been applied since inception to all patients in three groups including insured patients billed at 100of the fee schedule of The Medical Association of the Bahamas for the procedures performed, private self-pay and government patients billed at 75and 50respectively. Their respective distribution and contributions to total revenue was analyzed. A series of financial models were constructed taking into consideration variables that could influence the percentages of revenues collected from each sector and the number of individuals served RESULTS: One thousand five-hundred and forty-two patients received services in BICC over the 8.5 year period (56males and 44females age range: 0.25 - 96 years, with mean age of 55.7 years). One thousand eight-hundred and eighty-eight patient-procedures were performed, with 51insured generating 69total revenue, 18Private producing 16Revenue, and 31Government patients generating 15. Financial models were created to predict revenue behaviour in various scenarios. CONCLUSION: Partnered Care is a viable alternative for Governments (Ministries of Health) of developing countries to provide costly specialized healthcare to their populations at minimal expense and capital outlay. Partnered Care reduces the otherwise overwhelming burden of healthcare cost to governments, particularly in developing countries, by sharing the burden of care between the private, user and government sectors.

OBJETIVO: Evaluar la prestación de servicios médicos especializados avanzados, usando el modelo de cuidados mediante asociación, como medio de proporcionar acceso económico a todos, con independencia de su capacidad de pago. DISEÑO Y MÉTODOS: Se llevó a cabo un análisis retrospectivo de todas las personas que acudieron a una unidad privada de cardiología – The Bahamas Interventional Cardiology Center (BICC) – por un periodo del 8.5 años, a saber, de marzo de 1996 a septiembre de 2004. El sistema de servicio de descuentos del Centro Cardiológico de Bahamas, había sido aplicado desde el principio a todos los pacientes en tres grupos. Los mismos comprendían: los pacientes con seguro – quienes pagaban el 100% de la suma estipulada por la Asociación Médica de Bahamas para los procedimientos realizados, los pacientes privados auto-financiados, y los pacientes con asistencia gubernamental, que abonaban 75% y 50% respectivamente. Se analizó su distribución respectiva y sus contribuciones al ingreso total. Se construyó una serie de modelos financieros tomando en consideración las variables que podrían influir en los porcentajes de ingresos percibidos por cada sector así como el número de individuos atendidos. RESULTADOS: Mil quinientos cuarenta y dos pacientes recibieron servicios en el BICC por espacio de 8.5 años (56% hombres y 44% mujeres). El rango de edad: 0.25–96 años, con una edad media de 55.7 años). Se realizaron mil ochocientos ochenta y ocho procedimientos por los cuales el 51% constituido por los asegurados generó un ingreso total del 69%; el 18% formado por los privados produjo un ingreso del 17%; y el 31% representado por los pacientes gubernamentales generó una entrada del 15%. Se crearon modelos financieros a fin de predecir el comportamiento de los ingresos en diversos escenarios. CONCLUSIÓN: El cuidado mediante asociación es una alternativa viable, mediante la cual los gobiernos (los ministerios de salud) de los países en vías de desarrollo pueden brindar a sus respectivas poblaciones, servicios de salud especializados – que de otra forma serían costosos – con costos y desembolso de capital mínimos. Los cuidados mediante asociación reducen la carga del costo de la atención a la salud para los gobiernos – carga que de otra forma resultaría realmente abrumadora, especialmente en los países en vías de desarrollo. Esto se logra mediante el procedimiento de compartir la carga de los cuidados médicos entre los tres sectores referidos – el de los usuarios, el privado, y el gubernamental.

Recursos necesarios en la mejora de la salud pública en obstetricia y ginecología / Resources required for the improvement of public health in obstetrics and ginecology

No disponible

Alcances de las visitas domiciliarias efectuada en la zona de Tupac Amarú, independencia por los estudiantes de la Universidad Peruana Cayetano Heredia / Domiciliary visit achievements effected in Tupac Amaru, independencia by the students of Cayetano Heredia Peruvian University

Se muestran alcances de visitas domiciliarias efectuadas en Túpac Amaru, por estudiantes de la Universidad Peruana Cayetano Heredia durante mayo de 1990, basados en hojas censales y hojas de visitas domiciliarias de 433 familias.Se efectuaron 63 visitas (12 por ciento de las familias). 81 por ciento fueron efectivas: en el cerro 94.7 por ciento, en el plano 60 por ciento. Se visitó al 85 por ciento de gestantes y 28.9 por ciento de niños menores de un año.Asentamientos Humanos con menos de 4 años de antiguedad y familias que viven a menos de 1000 metros del centro de salud fueron mas visitados. 76.1 por ciento de visitas tuvo un solo motivo registrado, mayormente seguimiento de pacientes.El cumplimiento del llenado de datos censales fue 69.8 por ciento.Se incluye que las visitas domiciliarias fueron altamente efectivas; más frecuentemente en zonas de cerro, menos antiguas y mas cercanas.Gestantes y niños menores de un año fueron los grupos mas visitados.La mayoria de visitas tuvo un motivo registrado: seguimiento de pacientes.Utilizar formularios para registrar la visita brinda buena información del trabajo efectuado