Costs and consequences of the Portuguese needle-exchange program in community pharmacies.

BACKGROUND: Needle-exchange programs (NEPs) reduce infections in people who inject drugs. This study assesses the impact community pharmacies have had in the Needle-Exchange Program in Portugal since 2015. METHODS: Health gains were measured by the number of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections averted, which were estimated, in each scenario, based on a standard model in the literature, calibrated to national data. The costs per infection were taken from national literature; costs of manufacturing, logistics and incineration of injection materials were also considered. The results were presented as net costs (i.e., incremental costs of the program with community pharmacies less the costs of additional infections avoided). RESULTS: Considering a 5-year horizon, the Needle Exchange Program with community pharmacies would account for a 6.8% (n = 25) and a 6.5% reduction (n = 22) of HCV and HIV infections, respectively. The present value of net savings generated by the participation of community pharmacies in the program was estimated at €2,073,347. The average discounted net benefit per syringe exchanged is €3.01, already taking into account a payment to community pharmacies per needle exchanged. INTERPRETATION: We estimate that the participation of community pharmacies in the Needle Exchange Program will lead to a reduction of HIV and HCV infections and will generate over €2 million in savings for the health system. CONCLUSIONS: The intervention is estimated to generate better health outcomes at lower costs, contributing to improving the efficiency of the public health system in Portugal.

The impact of osteoarthritis on early exit from work: results from a population-based study.

BACKGROUND: Osteoarthritis (OA) is a leading cause of pain and disability, which may be a source of productivity losses. The objectives of this study were to describe the impact of OA, namely through pain and physical disability, on early exit from work and to calculate its economic burden. METHODS: We analysed data from the national, cross-sectional, population-based EpiReumaPt study (Sep2011-Dec2013) in which 10,661 individuals were randomly surveyed in order to capture all cases of rheumatic diseases. We used all participants aged 50-64, near the official retirement age, who were clinically validated by experienced rheumatologists (n = 1286), including OA cases. A national database was used to calculate productivity values by gender, age and region, using the human capital approach. The impact of OA on the likelihood of early exit from work and the population attributable fractions used to calculate due economic burden (indirect costs) were obtained at the individual level by logistic regression. All results were based on weighted data. RESULTS: Almost one third of the Portuguese population aged 50-64 had OA (29.7%; men: 16.2% and women: 43.5%) and more than half were out of paid work (51.8%). Only knee OA is associated with early exit from work (OR: 2.25; 95%CI: 1.42-3.59; p = 0.001), whereas other OA locations did not reach any statistical difference. Furthermore, we observed an association between self-reported longstanding musculoskeletal pain (OR: 1.55; 95%CI: 1.07-2.23; p = 0.02) and pain interference (OR: 1.35; 95%CI: 1.13-1.62; p = 0.001) with early exit from work. We also detected a clear relationship between levels of disability, measured by the Health Assessment Questionnaire (HAQ), and the probability of work withdrawal. The estimated annual cost of early exit from work attributable to OA was €656 million (€384 per capita; €1294 per OA patient and €2095 per OA patient out-of-work). CONCLUSIONS: In this study, we observed an association between OA and early exit from work, largely dependent on pain and disability. This relationship translates into a meaningful economic burden amounting to approximately 0.4% of the national Gross Domestic Product (GDP). The high prevalence and the impact of this disabling chronic disease highlight the need to prioritize policies targeting early exit from work in OA.

Allergic contact dermatitis caused by dexpanthenol-Probably a frequent allergen.

BACKGROUND: Panthenol (synonym: dexpanthenol), the alcohol analogue of panthothenic acid, is frequently included in moisturizers, wound-healing agents, and other cosmetics, and has been shown to be responsible for allergic contact dermatitis (ACD). OBJECTIVES: To evaluate the frequency of ACD caused by dexpanthenol, and to characterize reactive patients. METHODS: We retrospectively reviewed the files of patients patch tested between 2009 and 2017 in the Department of Dermatology of the Coimbra's University Hospital and describe patients who reacted to dexpanthenol 5% pet., tested initially in a cosmetic/vehicle series and in the last 3 years in consecutive patients. RESULTS: Among 2171 patients, 26 (1.2%) had positive patch test reactions to dexpanthenol, mostly patients tested for chronic eczema (88.5%, n = 23), either widespread (5), or localized to the hands (5), face (4), or legs (7). Relevance could be traced in 20 patients (76.9%), related to the use of Bepanthene cream (15), moisturizers (3), topical medications (1), and a shampoo (1). Twenty-five of 26 patients (96.2%) reacted to several other allergens, mostly ingredients of cosmetic or pharmaceutical products. CONCLUSIONS: Although ACD caused by dexpanthenol is considered to be rare, it may be frequently overlooked. As we found a relatively high frequency of relevant cases, in agreement with a previous study, the inclusion of dexpanthenol in patch test series, at least in cosmetic and topical drug series, is encouraged.

Histopathology of the Exanthema in DRESS Is Not Specific but May Indicate Severity of Systemic Involvement.

OBJECTIVE: Exanthema in drug reaction with eosinophilia and systemic symptoms (DRESS) has no specific clinical diagnostic hallmark and there are few histopathologic studies. The aim of this study was to describe dermal-epidermal histopathologic features in DRESS and correlate them with the culprit drug, viral reactivation, or systemic organ involvement. METHODS: Skin biopsies were independently evaluated by 2 dermatopathologists who characterized the main histological patterns and scored dermal and epidermal changes, which were further correlated with clinical and laboratorial data. RESULTS: In 15 DRESS patients (9 male/6 female patients, mean age 53.3 years), the main observation was lymphocyte exocytosis (1.87 ± 1.25), spongiosis (0.93 ± 0.94), scattered keratinocyte necrosis (1.70 ± 1.44), basal cell vacuolization (2.13 ± 1.42), lymphocyte infiltration around dermal vessels (2.93 ± 0.92) or at the dermal-epidermal junction (2.07 ± 1.12), often with eosinophils and extravasated erythrocytes, swollen endothelial cells, and intravascular neutrophils but no vasculitis. Histopathologic patterns were classified mainly as spongiotic (5), erythema multiforme-like (3), or lichenoid (2). There was a significant positive correlation between the intensity of lymphocyte infiltration and the severity of hepatic cytolysis (r = 0.51; P < 0.05) and eosinophilia (r = 0.51; P < 0.05). No correlation was observed between the intensity and type of dermal inflammation and the degree of epidermal damage or the culprit drug. Human herpes virus type 6-positive patients had a pseudolymphomatous reaction or a perifollicular localization of the infiltrate. CONCLUSIONS: Histopathology in DRESS is variable with no specific diagnostic aspect, but there is a possible correlation between the intensity of the lymphocyte infiltrate and DRESS severity, namely, liver cytolysis.

Vancomycin-induced linear IgA bullous dermatosis: associations.

UNLABELLED: Linear IgA bullous dermatosis (LABD) is a rare autoimmune blistering disease. LABD is considered mostly idiopathic, butsome cases have been reported to be drug-induced, mainly associated with vancomycin (VCM).We present two cases of LABD possibly associated with VCM used for cardiac surgery prophylaxis; in the presented cases, the eruptions occurred only after VCM withdrawal, therefore leaving a question about the relationship between VCM and LABD in these cases.We reviewed previous reports of VCM-induced LABD and analyzed the following parameters: gender, age, recent medical history, concurrent medication, latency period, progression after withdrawal, time to resolution, treatment, and rechallenge. RESULTS: The causal relationship between VCM and LABD was often unclear; patients frequently had concurrent medication and symptoms frequently began and/or progressed after VCM withdrawal. Among the 46 reviewed patients in addition to our two cases (n=48), 20 (42%) had recent history of cardiac procedure, cardiac infection, congestive heart failure, or aortic aneurism. CONCLUSION: Further investigation is needed to ascertain the association between LABD, VCM, and heart disease.

Indirect costs associated with early exit from work attributable to rheumatic diseases.

BACKGROUND: Rheumatic diseases (RD) cause physical disability that may lead to early exit from work, generating indirect costs to society. We aimed to measure these costs in a population approaching the statutory retirement age. METHODS: The analysis was based on the prevalence of self-reported RD using a bottom-up approach. Health and sociodemographic data were retrieved from the fourth National Health Survey (INS), for all people between 50 and 64 years of age (3762 men and 4241 women), whereas an official national database was used to estimate productivity values by gender, age group and region, using the human capital approach. The effects of RD on the likelihood of early exit from paid employment and the attributable fractions estimates were obtained at the individual level by logistic regression. RESULTS: At the time of the survey, 37.2% of the population aged 50-64 years self-reported at least one RD. Among these, 52.6% were not employed, compared with 40.7% of those without RD (P < 0.001). The annual indirect costs following premature exit from work attributable to RD were €650 million (€892 per RD patient). Early retirement amounted to €367 million, whereas early retirement and unemployment totalized €385 million (€504 and €528 per RD patient, respectively). Females are responsible for about 60% of these costs; however, males contribute with higher individual productivity losses. CONCLUSION: Early exit from work attributable to RD amounts to approximately 0.4% of the national GDP. The public health concern and the economic impact highlight the need to prioritize investments in health and social protection policies targeting patients with rheumatic conditions.

Interstitial Granulomatous Dermatitis: A Clinicopathological Study.

INTRODUCTION: Interstitial granulomatous dermatitis (IGD) is an uncommon granulomatous dermatitis occurring in the setting of highly reactive immune states, with a polymorphic clinical presentation. Because there is overlap with other entities [namely palisading neutrophilic granulomatous dermatitis (PNGD)], controversy exists regarding its classification. OBJECTIVE: To understand if there are features allowing clear-cut distinction between IGD and PNGD. MATERIAL AND METHODS: Retrospective analysis of 10 cases previously diagnosed as IGD or PNGD, from 2000 to 2013, with review of the histopathologic findings and clinical correlation. RESULTS: Six females and 4 males presented mostly with erythematous papules/nodules (n = 7) but also with erythematous annular plaques (n = 3). In 2 patients, the lesions coexisted. They were mostly distributed symmetrically on the limbs. Associated disease was observed in 6 patients. Regarding histopathology, an inflammatory infiltrate occupying the superficial and mid dermis was present in 40% of cases, with an interstitial component in all biopsies and a palisaded arrangement in 60%. Neutrophils and mononuclear cells were present in all cases in varying proportions. Necrobiosis was found in 70%, and leukocytoclasia was observed in 80% of biopsies. CONCLUSIONS: Coexistence of the interstitial and palisaded inflammatory patterns occurred in 90% of cases, with no correlation between tissue neutrophilia and the predominant pattern of the infiltrate. There was also no clear-cut correlation between the infiltrate pattern and semiologic aspect of the lesions. Therefore, the features described in our study suggest that IGD and PNGD belong to the same clinicopathological spectrum.

Association of rheumatic diseases with early exit from paid employment in Portugal.

To examine the association between rheumatic diseases (RD) and other chronic morbidity with early exit from paid employment in the Portuguese population. The study population consisted of all people between 50 and 64 years of age (3,762 men and 4,241 women) who participated in the Portuguese National Health Survey, conducted in 2005/2006. Data were collected on demographics, ill-health, lifestyle, and socioeconomic factors. Logistic regression was used to estimate the isolated effect of rheumatic diseases and other chronic diseases on the likelihood of exit from paid employment. At the time of the survey, 45.1 % of the Portuguese population with ages between 50 and 64 years old were not employed. In the nonemployed population, 31.6 % self-reported "poor" to "very poor" health, whereas 16.4 % did so in the employed population. A larger average number of major chronic diseases per capita were also found in those not employed (1.9 vs. 1.4, p < 0.001). In the multivariate models, chronic diseases were associated with early exit from paid employment. In particular, rheumatic diseases were more prevalent (43.4 vs. 32.1 %) and associated with early exit from work (OR 1.31; CI 1.12-1.52, p = 0.001). This study suggests an association between RD and other major chronic diseases with early exit from paid employment in Portugal. Thus, health and social protection policies should target these chronic disorders in order to better address sustainability issues and social protection effectiveness.

Measuring the value of solidarity: The abem financial assistance program for out-of-pocket payments on pharmacy medicines in Portugal.

OBJECTIVE: Out-of-pocket payments for prescribed medicines are still comparatively high in Portugal. The abem program was launched in Portugal in May 2016 to aid vulnerable groups by completely covering out-of-pocket costs of prescribed medicines in community pharmacies. This study assesses the impact of the program on poverty and catastrophic health expenditures. METHODS: A longitudinal study was carried out with the analysis of several program databases (from the beginning of the program in May 2016 to September 2018) covering the cohorts of beneficiaries, daily data on medicines dispensed, social referencing entities, and solidarity pharmacies. The study provides estimates of standard poverty measures (intensity and severity) as well as the incidence of catastrophic health expenditures. RESULTS: More than 6000 beneficiaries were supported (56.8% female, 34.7% aged 65 or over), encompassing 127,510 medicines (mainly nervous system and cardiovascular system) with an average 26.9% co-payment (payments totalling €1.5 million). The program achieved substantial reductions in poverty (3.4% in intensity, 5.6% in severity), and eliminated cases with catastrophic health expenditures in medicines that would have affected 7.5% of the beneficiaries. CONCLUSIONS: Findings confirm a continuous increase in the number of beneficiaries, enabling access to medicines especially for the vulnerable elderly, and a sizable impact on eliminating out-of-pocket payments for medicines in the target population.

Partial Implant Rehabilitations in the Posterior Regions of the Jaws Supported by Short Dental Implants (7.0 mm): A 7-Year Clinical and 5-Year Radiographical Prospective Study.

Background: Short implants have been used in the restoration of edentulous jaws in the past several years. However, some studies have suggested that short implants are less successful than standard implants. The aim of this study is to investigate the outcome of short implants placed in the posterior maxilla or mandible following one-stage or immediate-function protocols with a follow-up of 7 years (clinically) and 5 years (radiographically). Methods: This study included 127 patients rehabilitated with 217 implants measuring 7 mm and supporting 157 fixed prostheses in the posterior segments of both jaws. Final abutments were delivered at the surgery stage and were loaded after 4 months in 116 patients (199 implants). The primary outcome measure was implant survival measured through life tables. Secondary outcome measures were marginal bone loss and the incidence of biological and mechanical complications at the patient level and implant level (evaluated through descriptive statistics). Results: Twenty-four patients (18.9%) with 45 implants (20.7%) were lost to the follow-up. In total, 32 implants failed (14.8%) in 22 patients (17.3%), resulting in a cumulative survival rate at 7 years of 81.2% for 7 mm implants in the rehabilitation of the posterior regions of the maxilla and mandible. The average (standard deviation) marginal bone loss was 1.47 mm (0.99 mm) at 5 years. The incidence rate of biological complications was 12.6% and 10.6% at the patient and implant levels, respectively. The incidence rate of mechanical complications was 21.3% for patients and 16.1% for implants. A higher failure rate was registered in smokers and in implant arrangements with a sequence of three fixtures in proximity. Conclusions: Within the limitations of this study, it can be concluded that the placement of 7 mm long implants for the partial implant-supported rehabilitation of atrophic posterior jaws is possible in the long term, judging by the survival rate and stable average marginal bone loss. Nevertheless, strict case selection should be performed, especially in smokers and with implant arrangements that provide a minimum of one unit in inter-implant distance.

Can kidney deceased donation systems be optimized? A retrospective assessment of a country performance.

BACKGROUND: The intensive requirement of organs for transplantation generates the need for higher rates of donation. METHODS: Using the national database of diagnosis-related groups for 2006, the global annual 2006 in-hospital mortality of 34 hospitals with organ-retrieval schemes was evaluated. Potential donors were estimated excluding patients aged <1 year or >70 years and presenting International Classification of Diseases, Ninth Revision codes that contraindicated organ donation. RESULTS: We identified 3838 potential donors (12.6% of in-hospital deaths); 46% came from eight hospitals, 80% came from the larger hospitals and 21% from intensive care units (ICU). In hospitals with a neurosurgical department, an office coordinator of procurement and transplantation (OCPT), a transplant centre and co-location of neurosurgical and transplant centre, we identified, respectively, 54, 30, 32 and 30% of all potential donors. The causes of death were 23% cerebrovascular disease, 3% cerebral tumour, 2.6% anoxic lesion and 2.5% head trauma. In the same period, there were 189 effective deceased kidney donors with traumatic diseases as the main cause of death. The mean conversion rate was 4.9% and was associated with demographical and hospital characteristics. Age of potential donors, existence of OCPT or transplant centre, ratio between ICU and hospital acute beds and mortality from labour accidents were predictors of being an effective donor. CONCLUSIONS: Health policies need to maximize the conversion of potential to effective donors and the performance of organ donation systems must be considered as an index of the quality of care.

Marginal Bone Loss and Pink Esthetic Evaluation of Narrow-Diameter Dental Implants for Single Crowns: 1-Year Prospective Clinical Study.

PURPOSE: The aims of this study were: (1) to quantify the marginal bone loss (MBL) of 3.3-mm narrow-diameter, bonelevel, titanium-zirconia (Ti-Zr) implants with two different surfaces in single restorations after a 1-year follow-up; (2) to analyze the combinations of different variables that may influence MBL; and (3) to record the Pink Esthetic Score (PES) value and its correlation with MBL. MATERIALS AND METHODS: This is a prospective longitudinal clinical study with a 1-year follow-up after crown placement. Two different implant surfaces (sandblasted acid-etched and modified sandblasted acid-etched) were used. All bone-level and bone level-tapered implants had a diameter of 3.3 mm. Different healing and prosthetic abutments were used. Clinical, radiographic, and photographic records were taken 6 months and 1 year after placement of the restorations, and the survival rate, MBL, PES, clinical parameters, and biologic and/or mechanical complications were assessed. The correlations between the variables and MBL were verified. RESULTS: A total of 30 narrowdiameter implants were placed in 30 patients; 18 implants had a sandblasted acid-etched surface, and 12 implants had a modified sandblasted acid-etched surface. The measured MBL at 1 year after implant function had a mean value of -0.36 mm, ranging from 0 mm to -1.77 mm. There was no implant loss. A statistically significant relationship was observed between implant shape (design and length), implant placement level, healing abutment, prosthetic abutment size, gingival thickness, and MBL. The mean PES values recorded at the beginning and end of the study were 7.58 and 11.37, respectively. CONCLUSION: Narrow-diameter implants showed reduced MBL values, with the surrounding tissues remaining stable after 1 year of follow-up. The MBL did not show different values on two implant surfaces. MBL does not seem to influence esthetic outcome.

Treatment-resistant depression and major depression with suicide risk-The cost of illness and burden of disease.

Introduction: Treatment-Resistant Depression (TRD) and Major Depression with Suicide Risk (MDSR) are types of depression with relevant effects on the health of the population and a potentially significant economic impact. This study estimates the burden of disease and the costs of illness attributed to Treatment-Resistant Depression and Major Depression with Suicide Risk in Portugal. Methods: The disease burden for adults was quantified in 2017 using the Disability-Adjusted Life Years (DALYs) lost. Direct costs related to the health care system and indirect costs were estimated for 2017, with indirect costs resulting from the reduction in productivity. Estimates were based on multiple sources of information, including the National Epidemiological Study on Mental Health, the Hospital Morbidity Database, data from the Portuguese National Statistics Institute on population and causes of death, official data on wages, statistics on the pharmaceutical market, and qualified opinions of experts. Results: The estimated prevalence of TRD, MDSR, and both types of depression combined was 79.4 thousand, 52.5 thousand, and 11.3 thousand patients, respectively. The disease burden (DALY) due to the disability generated by TRD alone, MDSR alone, and the joint prevalence was 25.2 thousand, 21 thousand, and 4.5 thousand, respectively, totaling 50.7 thousand DALYs. The disease burden due to premature death by suicide was 15.6 thousand DALYs. The estimated total disease burden was 66.3 thousand DALYs. In 2017, the annual direct costs with TRD and MDSR were estimated at € 30.8 million, with the most important components being medical appointments and medication. The estimated indirect costs were much higher than the direct costs. Adding work productivity losses due to reduced employment, absenteeism, presenteeism, and premature death, a total cost of € 1.1 billion was obtained. Conclusions: Although TRD and MDSR represent relatively small direct costs for the health system, they have a relevant disease burden and extremely substantial productivity costs for the Portuguese economy and society, making TRD and MDSR priority areas for achieving health gains.

Atherosclerosis in the primary health care setting: A real-word data study.

INTRODUCTION AND OBJECTIVES: To characterize patients with atherosclerosis, a disease with a high socioeconomic impact, in the Lisbon and Tagus Valley Health Region. METHODS: A cross-sectional observational study was carried out through the Lisbon and Tagus Valley Regional Health Administration primary health care database, extracting data on the clinical and demographic characteristics and resource use of adult primary health care users with atherosclerosis during 2016. Different criteria were used to define atherosclerosis (presence of clinical manifestations, atherothrombotic risk factors and/or consumption of drugs related to atherosclerosis). Comparisons between different subpopulations were performed using parametric tests. RESULTS: A total of 318 692 users were identified, most of whom (n=224 845 users; 71%) had no recorded clinical manifestations. The subpopulation with clinical manifestations were older (72.0±11.5 vs. 71.3±11.0 years), with a higher proportion of men (58.0% vs. 45.9%), recorded hypertension (78.3% vs. 73.5%) and dyslipidemia (55.8% vs. 53.5%), and a lower proportion of recorded obesity (18.2% vs. 20.8%), compared to those without clinical manifestations (p<0.001). Mean blood pressure, LDL-C and glycated hemoglobin values were lower in the subpopulation with manifestations (142/74 vs. 146/76 mmHg, 101 vs. 108 mg/dl, and 6.80 vs. 6.84%, respectively; p<0.001). Each user with atherosclerosis attended 4.1±2.9 face-to-face medical consultations and underwent 8.6±10.0 laboratory test panels, with differences in subpopulations with and without clinical manifestations (4.4±3.2 vs. 4.0±2.8 and 8.3±10.3 vs. 8.7±9.8, respectively; p<0.001). CONCLUSIONS: About one in three adult primary health care users with atherosclerosis have clinical manifestations. The results suggest that control of cardiovascular risk factors is suboptimal in patients with atherosclerosis.

The burden of atherosclerosis in Portugal.

AIMS: This article sought to estimate the burden of disease attributable to atherosclerosis in mainland Portugal in 2016. METHODS AND RESULTS: The burden of atherosclerosis was measured in disability-adjusted life years following the latest 2010 Global Burden of Disease (GBD) methodology. Disability-adjusted life years were estimated as the sum of years of life lost (YLL) with years lived with disability (YLD). The following clinical manifestations of atherosclerosis were included: ischaemic heart disease (IHD) (including acute myocardial infarction, stable angina, and ischaemic heart failure), ischaemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD). Years of life lost were estimated based on all-cause mortality data for the Portuguese population and mortality due to IHD, ICVD, and PAD for the year 2016 sourced from national statistics. Standard life expectancy was sourced from the GBD study. Years lived with disability corresponded to the product of the number of prevalent cases by an average disability weight for all possible combinations of disease. Prevalence data for the different clinical manifestations of atherosclerosis were sourced from epidemiological studies. Disability weights were sourced from the published literature. In 2016, 15 123 deaths were attributable to atherosclerosis, which corresponded to 14.3% of overall mortality in mainland Portugal. Disability-adjusted life years totalled 260 943, 75% due to premature death (196 438 YLL) and 25% due to disability (64 505 YLD). CONCLUSION: Atherosclerosis entails a high disease burden to society. A large part of this burden would be avoidable if evidence-based effective and cost-effective interventions targeting known risk factors, from prevention to treatment, were implemented.

Atherosclerosis: The cost of illness in Portugal.

INTRODUCTION AND OBJECTIVES: Cardiovascular disease is the leading cause of death in Portugal and atherosclerosis is the most common underlying pathophysiological process. The aim of this study was to quantify the economic impact of atherosclerosis in Portugal by estimating disease-related costs. METHODS: Costs were estimated based on a prevalence approach and following a societal perspective. Three national epidemiological sources were used to estimate the prevalence of the main clinical manifestations of atherosclerosis. The annual costs of atherosclerosis included both direct costs (resource consumption) and indirect costs (impact on population productivity). These costs were estimated for 2016, based on data from the Hospital Morbidity Database, the health care database (SIARS) of the Regional Health Administration of Lisbon and Tagus Valley including real-world data from primary care, the 2014 National Health Interview Survey, and expert opinion. RESULTS: The total cost of atherosclerosis in 2016 reached 1.9 billion euros (58% and 42% of which was direct and indirect costs, respectively). Most of the direct costs were associated with primary care (55%), followed by hospital outpatient care (27%) and hospitalizations (18%). Indirect costs were mainly driven by early exit from the labor force (91%). CONCLUSIONS: Atherosclerosis has a major economic impact, being responsible for health expenditure equivalent to 1% of Portuguese gross domestic product and 11% of current health expenditure in 2016.

The burden of disease and the cost of illness attributable to alcohol drinking--results of a national study.

BACKGROUND AND AIMS: The World Health Organization estimated that 3.2% of the burden of disease around the world is attributable to the consumption of alcohol. The aim of this study is to estimate the burden of disease attributable to alcohol consumption in Portugal. METHODS: Burden and costs of diseases attributable to alcohol drinking were estimated based on demographic and health statistics available for 2005, using the Disability-Adjusted Life Years (DALY) lost generated by death or disability. RESULTS: In Portugal, 3.8% of deaths are attributable to alcohol (4,059 of 107,839). After measuring the DALY generated by mortality data, the proportion of disease attributable to alcohol was 5.0%, with men having 5.6% of deaths and 6.2% of disease burden, while female figures were, respectively, 1.8 and 2.4%. Considering the sum of death and disability DALYs, liver diseases represented the main source of the burden attributable to alcohol with 31.5% of total DALYs, followed by traffic accidents (28.2%) and several types of cancer (19.2%). As for the cost of illness incurred by the health system, our results indicate that 95.1 millions euros are attributable to alcohol-related disease admissions (liver diseases, cancer, traffic accidents, and external causes) while the ambulatory costs of alcohol-related diseases were estimated in 95.9 million euros, totaling 191.0 million euros direct costs, representing 0.13% of Gross Domestic Product and 1.25% of total national health expenditures. An alternative analysis was carried out using higher consumption levels so as to replicate aggregate alcohol consumption statistics. In this case, DALYs lost increased by 11.7% and health costs by 23%. CONCLUSION: Our results confirm that alcohol is an important health risk factor in Portugal and a heavy economic burden for the health system, with hepatic diseases ranking first as a source of burden of disease attributable to alcohol.

Indirect costs of myocardial infarction in Portugal.

INTRODUCTION: Cardiovascular disease, and particularly myocardial infarction (MI), carries a significant economic burden, through productivity losses (indirect costs) associated with temporary absence from work, that has not yet been adequately studied in Portugal. Our objective was to quantify the indirect costs of MI in the first year after admission. METHODS: Consecutive patients admitted to a single center aged <66 years who survived to discharge during a one-year period were included. Employment status on admission was assessed and for every employed patient, their monthly wage was estimated from market wage rates taken from the Ministry of Labor database according to gender and age. The duration of temporary absence from work was assessed in follow-up contacts for up to one year. Indirect costs were calculated in this sample and the results were applied to the number of MIs in Portugal during 2016 and separately to ST-elevation MI (STEMI) and non-ST-elevation acute coronary syndrome. RESULTS: A total of 219 patients were included, of whom 66.2% were working. The mean monthly labor cost was 1802 euros. A total cost of 760 521.55 euros was obtained. At national level there were 4133 patients aged <66 years admitted with acute MI who survived to discharge. Costs were higher in STEMI patients and the total indirect cost was estimated at 10.12 million euros. CONCLUSIONS: In Portugal, the costs to society of disability-generated productivity losses exceed ten million euros in the first year after MI. Strategies to promote an earlier return to work are needed to lower these costs.

Cost-effectiveness of sacubitril/valsartan for the treatment of patients with heart failure with reduced ejection fraction in Portugal.

Objectives: This study assesses the cost-effectiveness of sacubitril/valsartan versus enalapril in patients with symptomatic heart failure with reduced ejection fraction (HFrEF).Methods: We used a previously developed Markov model calibrated with patient-level data from the PARADIGM-HF trial, adapted to the Portuguese setting. The model considers two health states (alive or dead) and uses regression analyzes to estimate hospitalizations and deaths over time. A panel of experts estimated resource consumption in the outpatient setting. To estimate resource consumption with hospitalizations, the National Health Service Diagnosis Related Groups database was used. Unit costs were based on national legislation, and on the Infomed database. The model considers a societal perspective, a time horizon of 30-years, and a 5% annual discount rate. Sensitivity analyses assessed the robustness of results.Results: Sacubitril/valsartan increases life expectancy by 0.5 life-years, corresponding to 0.4 incremental quality adjusted life-years (QALY) versus enalapril. The estimated incremental cost-effectiveness ratio (ICER) is 22,702€/QALY. Sensitivity analysis shows that results are robust, but sensitive to the parameter estimates of the cardiovascular survival curve.Conclusion: Sacubitril/valsartan is a cost-effective therapeutic option in the treatment of Portuguese patients with HFrEF and translate into significant health gains and increased life expectancy versus the current standard of care.

Current costs of heart failure in Portugal and expected increases due to population aging. / Os custos da insuficiência cardíaca em Portugal e a sua evolução previsível com o envelhecimento da população.

INTRODUCTION AND OBJECTIVES: Heart failure (HF) is a growing public health problem. This study estimates the current and future costs of HF in mainland Portugal. METHODS: Costs were estimated based on prevalence and from a societal perspective. The annual costs of HF included direct costs (resource consumption) and indirect costs (productivity losses). Estimates were mostly based on data from the Diagnosis-Related Groups database, real-world data from primary care, and the opinions of an expert panel. Costs were estimated for 2014 and, taking population aging into account, changes were forecast up to 2036. RESULTS: Direct costs in 2014 were €299 million (39% for hospitalizations, 24% for medicines, 17% for exams and tests, 16% for consultations, and the rest for other needs, including emergencies and long-term care). Indirect costs were €106 million (16% for absenteeism and 84% for reduced employment). Between 2014 and 2036, due to demographic dynamics, total costs will increase from €405 to €503 million. Per capita costs are estimated to rise by 34%, which is higher than the increase in total costs (+24%), due to the expected reduction in the resident population. CONCLUSIONS: HF currently has a significant economic impact, representing around 2.6% of total public health expenditure, and this is expected to increase in the future. This should be taken into account by health policy makers, alerting them to the need for resource management in order to mitigate the impact of this disease.