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.

Price setting in the Brazilian private health insurance sector.

Brazil's private health insurance market is the second largest in the world, behind only the United States, making it a valuable source of real-world evidence. This paper documents how physicians' inpatient reimbursement fees vary in the country and explores the relationship between these fees and the market share of health providers and health insurance companies. We implement a fixed-effects panel regression and take advantage of an unprecedented database that contains national administrative records of inpatient procedures paid by health insurance companies in 2016. We find a positive correlation between reimbursement for ICU procedures and provider market share. Conversely, we observe a negative correlation with insurers' market share. Additionally, we document substantial variation in procedure prices, both across and within Brazilian states, and observe that more competitive markets in Brazil tend to have higher population and GDP levels. Overall, our research enhances our understanding of the price setting dynamics of physician reimbursement fees in the context of a developing country. The insights gained from this study can assist policymakers in formulating appropriate regulations to ensure appropriate access to healthcare services.

HBA1C point-of-care testing for diabetes control in a low-income population: A before and after study and cost-parity analysis HbA1c point-of-care testing for diabetes control.

OBJECTIVE: To evaluate the results of a program that offered access to HbA1c POC tests for the glycemic control of patients with diabetes in small and poor municipalities of Minas Gerais, Brazil. METHODS: Using a before and after study, we compared four groups: patients submitted to (i) POC tests; (ii) conventional tests; (iii) both tests; and (iv) neither test. The analysis considered three periods: before the program; before the pandemic; and during the pandemic. A cost comparison was conducted under the societal perspective and a cost-parity model was designed. RESULTS: 1349 patients previously diagnosed with diabetes were included in the analysis. The rate of consultations and the rate of HbA1c testing were significantly different between all periods and groups. Group iii had a much higher consultation and testing rate. The costs were around 89.45 PPP-USD for POC tests and between 32.44 and 54.66 PPP-USD for conventional tests. Cost-parity analysis suggests that the technology would be acceptable if the annual number of tests was between 247 and 771. CONCLUSION: Using POC devices improved access to HbA1c testing but not glycemic control. Even in small towns, the number of tests necessary to achieve cost-parity is low enough to enable their incorporation into the public health system.

Spatial reorganization of the Brazilian Unified National Health System's inpatient care supply.

The joint provision of efficient and equitable healthcare service delivery is a critical factor in improving social welfare. However, healthcare services pose a particular challenge when balancing healthcare provider efficiency and equity. Typically characterized by economies of scale and scope, inpatient care involves a wide variety of medical care that usually demands a broad range of health professional expertise and technological complexity to ensure health care quality. This study analyzes the current spatial organization of the Brazilian general hospitals and their respective flow of patients to identify the possible benefits of closing inefficient hospitals. We studied how inpatient care referrals may be reallocated without increasing access inequities following the potential closure of inefficient public hospitals. We used data from the Brazilian Hospital Information System of the Brazilian Unified National Health System (SIH/SUS) and the Brazilian National Register of Health Establishments (CNES). The smallest and least efficient hospitals were selected as units for potential closure, conditioned on an optimization criterion that minimizes patient travel distances to the nearest efficient hospital. Our results show that there is room for hospital resource reorganization in Brazil without compromising health care access equity.

Censo das organizações sociais de saúde brasileiras: levantamento e caracterização / Census of Brazilian social health organizations: survey and characterization

Objetivo: Identificar e caracterizar os estabelecimentos geridos por Organizações Sociais de Saúde (OSSs) no Brasil. Métodos: A identificação desses estabelecimentos foi realizada mediante quatro procedimentos de busca por meio de pesquisa primária nos sítios das secretarias de saúde dos estados e dos municípios e consulta nos sítios das OSS e na Pesquisa de Informações Básicas Municipais do Instituto Brasileiro de Geografia e Estatística (IBGE), em 2018. Foi realizada uma análise descritiva dos estabelecimentos geridos por OSS comparando com as Administrações Diretas (ADs) segundo indicadores hospitalares. Resultados: Os estabelecimentos geridos por OSSs estão concentrados principalmente no Sudeste e no Sul do país, e 69% desses estabelecimentos são geridos por 20 OSSs. As OSSs estão mais presentes em hospitais-dia, seguidos de prontos atendimentos e de hospitais. A caracterização dos hospitais mostrou que aqueles administrados por OSSs apresentam melhor desempenho; contudo as diferenças diminuem à medida que se aumenta o porte do serviço. Os hospitais de maior porte apresentaram melhor desempenho em relação aos demais e é onde está concentrada a maior proporção de OSSs entre os hospitais. Conclusão: Este é o primeiro trabalho que faz uma identificação das OSSs em nível nacional. Essa listagem das OSSs é um instrumento importante de planejamento, monitoramento e organização da estrutura de oferta de serviços no Sistema Único de Saúde (SUS). Os resultados encontrados demonstram a necessidade de organização de uma base de dados administrativa que permita um acompanhamento do desempenho dos estabelecimentos no tempo.

Objective: To identify and characterize the Brazilians' establishments managed by the Social Health Organizations (OSS). Methods: The identification of these establishments was carried out through primary research on four search procedures on the websites of the health departments of the states and municipalities, and consultation on the websites of the OSS and in the Survey of Basic Municipal Information of the Brazilian Institute of Geography and Statistics (IBGE) in 2018. A descriptive analysis of the establishments managed by OSS was carried out comparing with the AD according to hospital indicators. Results: The OSS are concentrated mainly in the Southeast and South of the country, with 69% of these establishments are being managed by 20 social responsibility organizations. The establishments managed by OSS are concentrated mainly in the Southeast and South of the country, with 69% of these establishments managed by 20 OSS. The characterization of the hospitals shows that the OSS has a better performance than DA; however, the difference decreases as the size increases. Larger hospitals performed better than other sizes, and this is where the highest proportion of OSS is concentrated among hospitals. Conclusion: This is the first work that surveys the OSS at the national level. This list of OSS is an important tool for planning, monitoring, and organizing the structure of service provision in public health in Brazil. The results found demonstrate the need to organize an administrative database that allows a temporal monitoring of the establishments.

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

Correction: Transition to universal primary health care coverage in Brazil: Analysis of uptake and expansion patterns of Brazil's Family Health Strategy (1998-2012).

[This corrects the article DOI: 10.1371/journal.pone.0201723.].

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.

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.

Brazilian hospitals' performance: an assessment of the unified health system (SUS).

This paper assesses the economic efficiency of Brazilian general hospitals that provide inpatient care for the Unified Health System (SUS). We combined data envelopment analysis (DEA) and spatial analysis to identify predominant clusters, measure hospital inefficiency and analyze the spatial pattern of inefficiency throughout the country. Our findings pointed to a high level of hospital inefficiency, mostly associated with small size and distributed across all Brazilian states. Many of these hospitals could increase production and reduce inputs to achieve higher efficiency standards. These findings suggest room for optimization, but inequalities in access and the matching of demand and supply must be carefully considered in any attempt to reorganize the hospital system in Brazil.

Financiamento público da saúde nos municípios brasileiros: análise da qualidade dos registros declarados ao Siops de 2002 a 2014 para a atenção básica / Public health financing in brazilian municipalities: analysis of the quality of the records declared to the siops from 2002 to 2014 for primary health care

O Sistema de Informações sobre Orçamentos Públicos em Saúde (Siops) é um instrumento fundamental no entendimento da estrutura dos gastos municipais com saúde. Poucos trabalhos testam a confiabilidade das informações do sistema ao nível das subfunções. Este estudo propõe a análise da consistência dos registros do Siops considerando a desagregação para a subfunção atenção básica. Os registros foram analisados para o período 2002-2014. A confiabilidade das informações do Siops foi aferida através da construção de indicadores que associaram a presença de cobertura da Estratégia de Saúde da Família (ESF) à declaração de recebimento de transferências e de gastos com atenção básica. Os principais resultados mostram que os registros de receitas e despesas para a subfunção atenção básica melhoraram no período 2002-2014. Por sua vez, os registros de despesas específicas da ESF apresentaram alto nível de subdeclaração em grande parte dos municípios.

The Information System on Public Health Budgets (Siops) is a fundamental instrument to understand the structure of municipal health expenditures. Few papers test the reliability of the Siops information at the sub-function level. This study proposes the analysis of the consistency of Siops records considering the disaggregation for the primary health care sub-function. The records were analyzed for the period from 2002 to 2014. The reliability of Siops information was measured through the construction of indicators that associated the coverage by Family Health Strategy (FHS) with the declaration of receipt of transfers and expenditures for primary health care. The main results show that the records of income and expenses for the primary health care sub-function improved during the period from 2002 to 2014. On the other hand, the specific expenditure records of the FHS presented a high level of underreporting in most of the municipalities.

El Sistema de Información sobre Presupuestos Públicos en Salud (Siops) es un instrumento fundamental en el entendimiento de la estructura de los gastos municipales con salud. Pocos estudios prueban la confiabilidad de la información del sistema en el nivel de las cubfunciones. Este estudio propone el análisis de la consistencia de los registros del Siops considerando la desagregación para la subfunción atención primaria de salud. Los registros fueron analizados desde 2002 hasta 2014. La confiabilidad de las informaciones del Siops fue evaluada por la construcción de indicadores que asociaron la presencia de cobertura de la Estrategia de Salud de la Familia (ESF) a la declaración de recepción de transferencias y de gastos con atención primaria de salud. Los principales resultados muestran que los registros de ingresos y gastos para la subfunción atención primaria de Salud mejoraron en el período de 2002 al 2014. Por otro lado, los registros de gastos específicos de la ESF presentaron alto nivel de subdeclaración en gran parte de los municipios

Le Système d'Information sur les Budgets Publics en Santé (Siops) est un instrument fondamental pour comprendre la structure des dépenses de santé municipales. Peu d'articles testent la fiabilité des informations système au niveau des sous-fonctions. Cette étude propose l'analyse de la cohérence des enregistrements Siops compte tenu de la désagrégation pour la sous-fonction attention basique. Les enregistrements ont été analysés pour la période de 2002 à 2014. La fiabilité des informations Siops a été mesurée à travers la construction d>indicateurs associant la présence de la couverture de la Stratégie de la Santé Familiale (ESF) à la déclaration de réception des transferts et dépenses avec attention de base. Les principaux résultats montrent que les comptes de recettes et dépenses de la sous-fonction soins de base se sont améliorés entre 2002 et 2014. En revanche, les dossiers de dépenses spécifiques du ESF ont présenté un niveau élevé de sous-déclaration dans la plupart des municipalités.

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.

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.

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

Brazil's unified health system: the first 30 years and prospects for the future.

In 1988, the Brazilian Constitution defined health as a universal right and a state responsibility. Progress towards universal health coverage in Brazil has been achieved through a unified health system (Sistema Único de Saúde [SUS]), created in 1990. With successes and setbacks in the implementation of health programmes and the organisation of its health system, Brazil has achieved nearly universal access to health-care services for the population. The trajectory of the development and expansion of the SUS offers valuable lessons on how to scale universal health coverage in a highly unequal country with relatively low resources allocated to health-care services by the government compared with that in middle-income and high-income countries. Analysis of the past 30 years since the inception of the SUS shows that innovations extend beyond the development of new models of care and highlights the importance of establishing political, legal, organisational, and management-related structures, with clearly defined roles for both the federal and local governments in the governance, planning, financing, and provision of health-care services. The expansion of the SUS has allowed Brazil to rapidly address the changing health needs of the population, with dramatic upscaling of health service coverage in just three decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographical inequalities, insufficient funding, and suboptimal private sector-public sector collaboration. Fiscal policies implemented in 2016 ushered in austerity measures that, alongside the new environmental, educational, and health policies of the Brazilian government, could reverse the hard-earned achievements of the SUS and threaten its sustainability and ability to fulfil its constitutional mandate of providing health care for all.

Transition to universal primary health care coverage in Brazil: Analysis of uptake and expansion patterns of Brazil's Family Health Strategy (1998-2012).

Family Health Strategy, the primary health care program in Brazil, has been scaled up throughout the country, but its expansion has been heterogeneous across municipalities. We investigate if there are unique municipal characteristics that can explain the timing of uptake and the pattern of expansion of the Family Health Strategy from years 1998 to 2012. We categorized municipalities in six groups based on the relative speed of the Family Health Strategy uptake and the pattern of Family Health Strategy coverage expansion. We assembled data for 11 indicators for years 2000 and 2010, for 5,507 municipalities, and assessed differences in indicators across the six groups, which we mapped to examine spatial heterogeneities. Important factors differentiating early and late adopters of the Family Health Strategy were supply of doctors and population density. Sustained coverage expansion was related mainly to population size, marginal benefits of the program and doctors' supply. The uptake was widespread nationwide with no distinct patterns among regions, but highly heterogeneous at the state and municipal level. The Brazilian experience of expanding primary health care offers three lessons in relation to factors influencing diffusion of primary health care. First, the funding mechanism is critical for program implementation, and must be accompanied by ways to support the supply of primary care physicians in low density areas. Second, in more developed and bigger areas the main challenge is lack of incentives to pursue universal coverage, especially due to the availability of private insurance. Third, population size is a crucial element to guarantee coverage sustainability over time.

Electronic Version of the EQ-5D Quality-of-Life Questionnaire: Adaptation to a Brazilian Population Sample.

OBJECTIVES: To assess the measurement equivalence of the original paper version of an adapted tablet version of the EuroQol five-dimensional questionnaire (EQ-5D). METHODS: A randomly selected sample of 509 individuals aged 18 to 64 years from the general population responded to the EQ-5D at two time points separated by a minimum interval of 24 hours and were allocated to one of the following groups: test-retest group (tablet-tablet) or crossover group (paper-tablet and tablet-paper). Agreement between methods was determined using the intraclass correlation coefficient (ICC) and the κ coefficient. RESULTS: In the crossover group, the following ICC values were obtained: 0.76 (confidence interval [CI] 0.58-0.89) for EQ-5D scores and 0.77 (CI 0.68-0.84) for visual analogue scale in subjects responding first to the tablet version; 0.83 (CI 0.75-0.89) for EQ-5D scores and 0.75 (CI 0.67-0.85) for visual analogue scale in subjects responding first to the paper version. In the test-retest group, the ICC was 0.85 (CI 0.73-0.91) for EQ-5D scores and 0.79 (CI 0.66-0.87) for visual analogue scale. The κ values were higher than 0.69 in this group. The internal consistencies of the paper and tablet methods were similar. CONCLUSIONS: The paper and tablet versions of the EQ-5D are equivalent. Test-retest and crossover agreement was high and the acceptability of the methods was similar among individuals.

Brazil's Family Health Strategy: factors associated with programme uptake and coverage expansion over 15 years (1998-2012).

Universal Health Coverage (UHC) is one of the United Nations Sustainable Development Goals (SDGs). Achieving UHC will require strong health systems to promote and deliver equitable and integrated healthcare services through primary healthcare (PHC). In Brazil, the Family Health Strategy (FHS) delivers PHC through the public health system. Created in 1994, the FHS covered almost 123 million individuals (63% of the Brazilian population) by 2015. The FHS has been associated with many health improvements, but gaps in coverage still remain. This article examines factors associated with the implementation and expansion of the FHS across 5419 Brazilian municipalities from 1998 to 2012. The proportion of the municipal population covered by the FHS over time was assessed using a longitudinal multilevel model for change that accounted for variables covering eight domains: economic development, healthcare supply, healthcare needs/access, availability of other sources of healthcare, political context, geographical isolation, regional characteristics and population size. Data were obtained from multiple publicly available sources. During the 15-year study period, national coverage of the FHS increased from 4.4% to 54%, with 58% of the municipalities having population coverage of 95% or more, and municipalities that had not adopted the programme decreased from 86.4% to 4.9%. The increase in FHS uptake and coverage was not homogenous across municipalities, and was positively associated with small population size, low population density, low coverage of private health insurance, low level of economic development, alignment of the political party of the Mayor and the state Governor, and availability of healthcare supply. Efforts to expand the FHS coverage will need to focus on increasing the availability of health personnel, devising financial incentives for municipalities to uptake/expand the FHS and devising new policies that encompass both private and public sectors.