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.

Medical adhesive-related skin injuries in the neonatology department of a teaching hospital.

BACKGROUND: Medical adhesives are used to affix components to the skin. They are part of procedures performed by medical specialties because of their participation as constituents of different products, such as tapes, dressings, and electrodes. AIM: This study aims to assess the prevalence of, and factors associated with, the development of medical adhesive-related skin injuries (MARSIs) in patients treated with medical tapes in the neonatology department of a large teaching hospital in Brazil. STUDY DESIGN: Cohort study. METHODS: All premature newborns (gestational age from 28 to <37 weeks) admitted in the neonatal intensive care unit of a teaching hospital, from March to August 2019, were followed up. Neonate skin condition was assessed based on the Neonatal Skin Condition Scale (NSCS). Data analyses were conducted in R software. RESULTS: In total, 46 premature newborns were included in the study; 552 evaluations were performed-mean of 11.7 per patient. Most neonates (n = 41; 89.1%) used adhesive tapes, either paper tape (n = 37; 80.4%) or transparent film dressing (n = 34; 73.9%). Newborns' face and head were the most affected body regions (n = 125; 50.2%). Eight patients had MARSIs (19.5% of patients who used tape). NSCS scores (P value <.001) and the adopted warming system (P value = .01302) were associated with the occurrence of MARSIs. Incubators seem to be a protective factor for MARSI (OR = 0.048; IC95% = 0.0008-0.75; P value = .013). CONCLUSION: Adhesive tapes in premature newborns should be considered a risk factor for injuries. Although NSCS showed mild-to-moderate impairment and lesion severity was low, this event is relatively frequent in neonatal units. RELEVANCE TO CLINICAL PRACTICE: Awareness of the risk associated with adhesive tape application and removal in newborns allow health services to better address the problem by enforcing good practices, elaborating better protocols, qualifying the health care professionals, and potentially selecting softer tapes for neonates.

Cost-effectiveness and Price of Aripiprazole for Schizophrenia in the Brazilian Public Health System

BACKGROUND: Schizophrenia is a chronic debilitating condition characterized by disorders in thought, affect and behavior. Considering the low effectiveness of antipsychotic drugs for schizophrenia and the potentially high cost of an inadequate choice, a systematic cost-effectiveness evaluation of the list of subsidized antipsychotic drugs is necessary in order to allow an adequate choice of pharmacotherapy for the patient and the financial reality of the Brazilian public health system (SUS). OBJECTIVE: The aims of this study are to conduct a cost-effectiveness analysis of the subsidized antipsychotic drugs for the first-line treatment of schizophrenia in Brazil and aripiprazole, and to discuss a reasonable incorporation price for aripiprazole. METHODS: A three-year Markov model with quarterly cycles was developed in TreeAge Pro® 2009 to assess the cost-effectiveness of six listed oral antipsychotic drugs for the first-line treatment of schizophrenia in the Brazilian public health system (haloperidol, chlorpromazine, risperidone, quetiapine, ziprasidone, and olanzapine) and oral aripiprazole. Outcomes were measured in quality-adjusted life years (QALYs). Reasonable prices for aripiprazole were calculated based on the placement of the drug in the efficiency frontier and the cost-effectiveness ratio of the most efficient comparator. RESULTS: Olanzapine was considered cost-effective adopting any threshold value. If me-too drugs are required to be least as efficient as the comparators, olanzapine would still be cost-effective under 0.031 USD/mg. Aripiprazole was absolutely dominated by risperidone. The sensitivity analysis showed important uncertainty, which was expected. There is, nevertheless, a prominent separation between ziprasidone, quetiapine and the efficiency frontier. Aripiprazole was not considered cost-effective even when its price was set at zero: CER = USD 4,102 vs. USD 3,945 (haloperidol), USD 3,616 (chlorpromazine), USD 3,646 (risperidone) and USD 3,752 (olanzapine) USD/QALY. CONCLUSION: Olanzapine was considered the most cost-effective drug for the first-line treatment of schizophrenia in Brazil. Aripiprazole was dominated by risperidone and was not considered cost-effective against olanzapine. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: This work demonstrated, using a price adjustment process, that there is no viable price that would make aripiprazole cost-effective for incorporation in the Brazilian public health system in the first-line of treatment of schizophrenia. The drug can be useful in specific cases, since individual variability of response to antipsychotic drugs is important.

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.

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.