RESUMO
Objetivo: Identificar os principais critérios e preferências na tomada de decisão em saúde para osteoporose pós-menopausa, por três grupos de stakeholders (n=3, cada): médicos; representantes de pacientes; gestores de saúde. Métodos: Uma estrutura de Análise de Decisão Multicritério (MCDA) foi realizada para gerar priorização entre tecnologias: uma revisão da literatura formou conjuntos de critérios; um painel online validou os critérios selecionados; o método AHP (Analytic Hierarchy Process) atribuiu pesos de importância para cada critério, por consenso. Resultados: Os critérios avaliados foram: eficácia (fraturas clínicas, vertebrais, não vertebrais e de quadril, densidade mineral óssea), segurança (eventos adversos e tolerabilidade), conveniência (adesão e comodidade posológica) e economia (razão de custo-efetividade incremental RCEI, custo por respondedor, impacto orçamentário e custos indiretos). Fraturas clínicas e de quadril apareceram nas primeiras posições para todos os grupos. Para os médicos, fratura de quadril (26,11%) e eventos adversos (14,64%) foram os principais critérios de priorização; para os representantes dos pacientes, fratura clínica (25,09%) e de quadril (22,84%), enquanto critérios econômicos receberam os menores pesos (1,2% a 0,98%), abaixo da comodidade posológica, por exemplo (4%). Gestores públicos priorizaram RCEI (19,44%) e fratura de quadril (16,21%). Conclusões: Os resultados apresentados têm potencial para auxiliar na tomada de decisão e priorização de tratamentos para osteoporose e estão em linha ao observado em estudos de preferência nesta área terapêutica. Embora os pesos finais tenham variado entre os grupos, os desfechos de eficácia que envolvem fraturas foram os critérios priorizados.
Objective: To identify the main criteria and preferences in healthcare decision-making for postmenopausal osteoporosis according to three stakeholder groups (n=3, each): physicians, patient representatives, and public healthcare managers. Methods: A multi-Criteria Decision Analysis framework was performed to generate prioritization rankings between technologies: a literature review formed sets of criteria; an online panel validated the pre-selected criteria; the Analytic Hierarchy Process (AHP) method assigned importance weights to each criterion by consensus. Results: The final weighted average included: efficacy (clinical fractures, new vertebral, non-vertebral, hip fractures, and bone mineral density), safety (clinically significant adverse events and tolerability), convenience (adherence and dosing convenience), and economics (incremental cost-effectiveness ratio ICER, cost per responder, budget impact and indirect costs). New hip and clinical fractures appeared in the top-five positions for all stakeholder groups. For physicians the main criteria were new hip fracture (26.11%) and adverse events (14.64%); similarly, for patient representatives, clinical fracture (25.09%) and new hip fracture (22.84%) were the most important ones, while economic criteria received the lowest weights (1,2% to 0,98%), below dosing convenience, for example (4%). Public healthcare managers prioritized ICER (19.44%) and new hip fractures (16.21%). Conclusions: The presented results have the potential to assist decision-making and treatment prioritization in postmenopausal osteoporosis. Although final weightings varied among stakeholders, efficacy outcomes involving fractures were the priority criteria for all of them. It is possible to observe similar results in previously published studies of preferences in osteoporosis.
Assuntos
Osteoporose , Teoria da Decisão , Técnicas de Apoio para a DecisãoRESUMO
Objetivo: Estimar a utilização de recursos e os custos médicos diretos associados às fraturas por fragilidade, sob as perspectivas do Sistema Único de Saúde (SUS) e do Sistema de Saúde Suplementar (SSS) no Brasil, por meio de abordagem de microcusteio. Métodos: Para a determinação do padrão de utilização de recursos, foi conduzida uma revisão da literatura sobre o manejo das fraturas por fragilidade (fêmur proximal, terço distal do rádio e vértebra). As condutas foram validadas por dois especialistas. Foram considerados apenas custos diretos, sob as perspectivas do SUS e do SSS como fontes pagadoras, a partir de listas oficiais de preços adequadas a cada categoria de custos e a cada perspectiva. Resultados: Os custos finais médios atribuídos ao tratamento cirúrgico da fratura de fêmur proximal, sob as perspectivas do SUS e do SSS, foram de R$ 5.612,13 e R$ 52.384,06, respectivamente. Para as fraturas do terço distal do rádio, os custos médios por paciente para o tratamento conservador e cirúrgico foram de R$ 661,53 e R$ 1.405,21, respectivamente, sob a perspectiva do SUS, e de R$ 8.917,75 e R$ 21.689,92, para a perspectiva privada. Quanto às fraturas vertebrais, os custos por paciente para o tratamento conservador e cirúrgico foram de R$ 1.165,93 e R$ 9.775,56, respectivamente, no cenário do SUS, e de R$ 15.053,32 e R$ 54.596,78, respectivamente, sob a perspectiva do SSS. Conclusões: No Brasil, custos diretos das fraturas por fragilidade são relevantes, justificando a preocupação não apenas clínica, mas também econômica para fontes pagadoras e sociedade
Objective: To estimate the resources utilization, and direct medical costs associated with fragility fractures, from the perspectives of the Unified Healthcare System (SUS) and Supplementary Healthcare System (SSS) in Brazil, through a microcosting approach. Methods: A literature review was conducted regarding the management of fragility fractures (proximal femur, distal radius third of the radius and vertebra) to determine the pattern of resource utilization. The methods were validated by two experts. Only direct costs were considered, from the perspectives of SUS and SSS as paying sources, based on official price lists appropriate to each cost category and perspective. Public bid databases provide the actual market prices for the SUS perspective. Results: The average final costs attributed to the surgical treatment of the proximal femur fractures from the perspectives of SUS and SSS were BRL 5,612.13 and BRL 52,384.06, respectively. For fractures of the distal radius, the average costs per patient for conservative and surgical treatment were BRL 661.53 and BRL 1,405.21, respectively, from the SUS perspective, and BRL 8,917.75 and BRL 21,689.92, from the private perspective. For vertebral fractures, the cost per patient for conservative and surgical treatment were BRL 1.165,93 and BRL 9.775,56, respectively, in the SUS scenario and BRL 15.053,32 and BRL 54.596,78, respectively, under the SSS perspective. Conclusions: In Brazil, direct costs of fragility fractures are substantial, justifying not only clinical but also economic concerns for payers and society
Assuntos
Osteoporose , Custos e Análise de Custo , Fraturas Ósseas , Fraturas por OsteoporoseRESUMO
Breast cancer is a global public health problem and accumulating evidence indicates early-life exposures as relevant factors in the disease risk determination. Recent studies have shown that paternal nutrition can influence offspring health including breast cancer risk. Selenium is a micronutrient with essential role in central aspects of embryogenesis, male fertility and cancer and that has been extensively studied as a chemopreventive agent in several breast cancer experimental models. Thus, we designed an animal study to evaluate whether paternal selenium deficiency or supplementation during preconception could affect the female offspring mammary gland development and breast cancer susceptibility. Male Sprague-Dawley rats were fed AIN93-G diet containing 0.15 ppm (control diet), 0.05 ppm (deficient diet) or 1 ppm (supplemented diet) of selenium for 9 weeks and mated with control female rats. Mammary carcinogenesis was induced with 7,12-dimethylbenz[a]anthracene (DMBA) in their female offspring. Paternal selenium deficiency increased the number of terminal end buds, epithelial elongation and cell proliferation in the mammary gland of the female rat offspring and these effects were associated with higher susceptibility to DMBA-induced mammary tumors (increased incidence and higher grade tumors). On the other hand, paternal selenium supplementation did not influence any of these parameters. These results highlight the importance of father's nutrition including selenium status as a relevant factor affecting daughter's breast cancer risk and paternal preconception as a potential developmental stage to start disease preventive strategies.