Evaluación del impacto sanitario del Programa Estaciones Saludables en la Ciudad Autónoma de Buenos Aires, Argentina

[RESUMEN]. Objetivo. Explorar las motivaciones y expectativas de los usuarios del Programa de Estaciones Saludables en la Ciudad Autónoma de Buenos Aires y evaluar su potencial impacto sanitario. Métodos. Se realizaron entrevistas en profundidad (n = 34) y una encuesta autoadministrada (n = 605) a usuarios del programa. Se desarrolló un modelo epidemiológico para estimar el impacto del programa sobre los eventos cardiovasculares y los años de vida ajustados por discapacidad (AVAD). Resultados. Los principales factores motivadores para el uso de las estaciones saludables fueron la accesibilidad geográfica, económica (servicios gratuitos) y la satisfacción con la atención recibida. El 14,4% (intervalos de confianza del 95% [IC95%] 10,3–18,5%) de los usuarios hipertensos y el 24,8% (IC95% 17,6–32,0%) de los diabéticos informó haberse enterado de sus valores alterados en las estaciones saludables. Más de la mitad de los encuestados reportó alguna mejora de conocimientos sobre los beneficios de realizar actividad física y una alimentación saludable; esto fue más frecuente entre los usuarios más jóvenes, de menor nivel educativo, usuarios del sistema público de salud, usuarios de estaciones saludables de la zona sur y los que tenían algún factor de riesgo cardiometabólico (p<0.05). Se estimó que debido a la existencia de estaciones saludables se evitarían 12,5 eventos cardiovasculares y cerebrovasculares por año en la población asistida (4,75 eventos/100 000 personas) y 47,75 AVAD por estas causas. Conclusiones. Las estaciones saludables resultan un espacio propicio para la implementación de acciones de promoción de la salud y prevención, contribuyendo en la detección y facilitando el monitoreo de los factores de riesgo, con potencialidad para prevenir eventos cardiovasculares y sus consecuencias.

[ABSTRACT]. Objective. To explore the motivations and expectations of the users of the Program for Healthy Centers in the Autonomous City of Buenos Aires and to evaluate its potential health impact. Methods. In-depth interviews were conducted (n = 34) and a self-administered survey was sent to users of the program (n = 605). An epidemiological model was developed to estimate the impact of the program on cardiovascular events (CVE) and disability-adjusted life years (DALYs). Results. The main motivating factors for using the healthy centers were geographic and economic accessibility (free services) and satisfaction with the care received. 14.4% (95% CI, 10.3-18.5%) of hypertensive users and 24.8% (95% CI, 17.6-32.0%) of diabetic users reported having learned of their altered values in the healthy center. More than half of the respondents reported some improvement in their knowledge about the benefits of physical activity and healthy eating; this was more frequent among those who were younger, of lower educational level, users of the public health system, users of a healthy center in the South zone and those who had a cardiometabolic risk factor (p<0.05). It was estimated that the healthy centers would prevent 12.5 cardiovascular and cerebrovascular events per year in the assisted population (4.75 events/100 000) and 47.75 DALYs due to these causes. Conclusions. The healthy centers are a favorable space for the implementation of health promotion and prevention actions, contributing to the detection of and facilitating the monitoring of risk factors, with a potential to prevent cardiovascular events and its consequences.

[RESUMO]. Objetivo. Explorar as motivações e expectativas dos usuários do Programa Estações Saudáveis na Cidade Autônoma de Buenos Aires e avaliar seu impacto potencial na saúde. Métodos. Foram realizadas entrevistas em profundidade (n = 34) e uma pesquisa auto-administrada (n = 605) a usuários do programa. Um modelo epidemiológico foi desenvolvido para estimar o impacto do programa em eventos cardiovasculares e anos de vida ajustados por incapacidade (DALY). Resultados. Os principais fatores motivadores para o uso do estações saudáveis foram a acessibilidade geográfica, econômica (serviços gratuitos) e a satisfação com o atendimento recebido. 14,4% (intervalo de confiança de 95% [IC95%] 10,3-18,5%) de usuários hipertensos e 24,8% (IC95% 17,6-32,0%) dos diabéticos relataram ter aprendido sobre seus valores alterados na estação saudável. Mais da metade dos entrevistados relataram alguma melhora no conhecimento sobre os benefícios da atividade física e da alimentação saudável, com maior freqüência entre os mais jovens, de menor escolaridade, usuários do sistema público de saúde, usuários de estações saudáveis na zona sul e aqueles que apresentaram algum fator de risco cardiometabólico (p<0,05). Estimou-se que, devido à existência de estações saudáveis, 12,5 eventos cardiovasculares e cerebrovasculares por ano seriam evitados na população atendida (4,75 eventos/100 000) e 47,75 DALY por essas causas. Conclusões. As estações saudáveis são um espaço propício para a implementação de ações de promoção e prevenção da saúde, contribuindo para a detecção e facilitação do monitoramento dos fatores de risco, com potencial para prevenir os eventos cardiovasculares e suas consequências.

Measuring the Benefits of Healthcare: DALYs and QALYs - Does the Choice of Measure Matter? A Case Study of Two Preventive Interventions.

BACKGROUND: The measurement of health benefits is a key issue in health economic evaluations. There is very scarce empirical literature exploring the differences of using quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs) as benefit metrics and their potential impact in decision-making. METHODS: Two previously published models delivering outputs in QALYs, were adapted to estimate DALYs: a Markov model for human papilloma virus (HPV) vaccination, and a pneumococcal vaccination deterministic model (PNEUMO). Argentina, Chile, and the United Kingdom studies were used, where local EQ-5D social value weights were available to provide local QALY weights. A primary study with descriptive vignettes was done (n = 73) to obtain EQ-5D data for all health states included in both models. Several scenario analyses were carried-out to evaluate the relative importance of using different metrics (DALYS or QALYs) to estimate health benefits on these economic evaluations. RESULTS: QALY gains were larger than DALYs avoided in all countries for HPV, leading to more favorable decisions using the former. With discounting and age-weighting - scenario with greatest differences in all countries - incremental DALYs avoided represented the 75%, 68%, and 43% of the QALYs gained in Argentina, Chile, and United Kingdom respectively. Differences using QALYs or DALYs were less consistent and sometimes in the opposite direction for PNEUMO. These differences, similar to other widely used assumptions, could directly influence decision-making using usual gross domestic products (GDPs) per capita per DALY or QALY thresholds. CONCLUSION: We did not find evidence that contradicts current practice of many researchers and decision-makers of using QALYs or DALYs interchangeably. Differences attributed to the choice of metric could influence final decisions, but similarly to other frequently used assumptions.

[Health impact assessment of the Program Healthy Centers in the Autonomous City of Buenos Aires, ArgentinaAvaliação do impacto na saúde do Programa Estações Saudáveis na Cidade Autônoma de Buenos Aires, Argentina]. / Evaluación del impacto sanitario del Programa Estaciones Saludables en la Ciudad Autónoma de Buenos Aires, Argentina.

OBJECTIVE: To explore the motivations and expectations of the users of the Program for Healthy Centers in the Autonomous City of Buenos Aires and to evaluate its potential health impact. METHODS: In-depth interviews were conducted (n = 34) and a self-administered survey was sent to users of the program (n = 605). An epidemiological model was developed to estimate the impact of the program on cardiovascular events (CVE) and disability-adjusted life years (DALYs). RESULTS: The main motivating factors for using the healthy centers were geographic and economic accessibility (free services) and satisfaction with the care received. 14.4% (95% CI, 10.3-18.5%) of hypertensive users and 24.8% (95% CI, 17.6-32.0%) of diabetic users reported having learned of their altered values in the healthy center. More than half of the respondents reported some improvement in their knowledge about the benefits of physical activity and healthy eating; this was more frequent among those who were younger, of lower educational level, users of the public health system, users of a healthy center in the South zone and those who had a cardiometabolic risk factor (p<0.05). It was estimated that the healthy centers would prevent 12.5 cardiovascular and cerebrovascular events per year in the assisted population (4.75 events/100 000) and 47.75 DALYs due to these causes. CONCLUSIONS: The healthy centers are a favorable space for the implementation of health promotion and prevention actions, contributing to the detection of and facilitating the monitoring of risk factors, with a potential to prevent cardiovascular events and its consequences.

OBJETIVO: Explorar as motivações e expectativas dos usuários do Programa Estações Saudáveis na Cidade Autônoma de Buenos Aires e avaliar seu impacto potencial na saúde. MÉTODOS: Foram realizadas entrevistas em profundidade (n = 34) e uma pesquisa auto-administrada (n = 605) a usuários do programa. Um modelo epidemiológico foi desenvolvido para estimar o impacto do programa em eventos cardiovasculares e anos de vida ajustados por incapacidade (DALY). RESULTADOS: Os principais fatores motivadores para o uso do estações saudáveis foram a acessibilidade geográfica, econômica (serviços gratuitos) e a satisfação com o atendimento recebido. 14,4% (intervalo de confiança de 95% [IC95%] 10,3-18,5%) de usuários hipertensos e 24,8% (IC95% 17,6-32,0%) dos diabéticos relataram ter aprendido sobre seus valores alterados na estação saudável. Mais da metade dos entrevistados relataram alguma melhora no conhecimento sobre os benefícios da atividade física e da alimentação saudável, com maior freqüência entre os mais jovens, de menor escolaridade, usuários do sistema público de saúde, usuários de estações saudáveis na zona sul e aqueles que apresentaram algum fator de risco cardiometabólico (p<0,05). Estimou-se que, devido à existência de estações saudáveis, 12,5 eventos cardiovasculares e cerebrovasculares por ano seriam evitados na população atendida (4,75 eventos/100 000) e 47,75 DALY por essas causas. CONCLUSÕES: As estações saudáveis são um espaço propício para a implementação de ações de promoção e prevenção da saúde, contribuindo para a detecção e facilitação do monitoramento dos fatores de risco, com potencial para prevenir os eventos cardiovasculares e suas consequências.

Evaluación del impacto sanitario del Programa Estaciones Saludables en la Ciudad Autónoma de Buenos Aires, Argentina / Health impact assessment of the Program Healthy Centers in the Autonomous City of Buenos Aires, Argentina / Avaliação do impacto na saúde do Programa Estações Saudáveis na Cidade Autônoma de Buenos Aires, Argentina

RESUMEN Objetivo Explorar las motivaciones y expectativas de los usuarios del Programa de Estaciones Saludables en la Ciudad Autónoma de Buenos Aires y evaluar su potencial impacto sanitario. Métodos Se realizaron entrevistas en profundidad (n = 34) y una encuesta autoadministrada (n = 605) a usuarios del programa. Se desarrolló un modelo epidemiológico para estimar el impacto del programa sobre los eventos cardiovasculares y los años de vida ajustados por discapacidad (AVAD). Resultados Los principales factores motivadores para el uso de las estaciones saludables fueron la accesibilidad geográfica, económica (servicios gratuitos) y la satisfacción con la atención recibida. El 14,4% (intervalos de confianza del 95% [IC95%] 10,3-18,5%) de los usuarios hipertensos y el 24,8% (IC95% 17,6-32,0%) de los diabéticos informó haberse enterado de sus valores alterados en las estaciones saludables. Más de la mitad de los encuestados reportó alguna mejora de conocimientos sobre los beneficios de realizar actividad física y una alimentación saludable; esto fue más frecuente entre los usuarios más jóvenes, de menor nivel educativo, usuarios del sistema público de salud, usuarios de estaciones saludables de la zona sur y los que tenían algún factor de riesgo cardiometabólico (p<0.05). Se estimó que debido a la existencia de estaciones saludables se evitarían 12,5 eventos cardiovasculares y cerebrovasculares por año en la población asistida (4,75 eventos/100 000 personas) y 47,75 AVAD por estas causas. Conclusiones Las estaciones saludables resultan un espacio propicio para la implementación de acciones de promoción de la salud y prevención, contribuyendo en la detección y facilitando el monitoreo de los factores de riesgo, con potencialidad para prevenir eventos cardiovasculares y sus consecuencias.

ABSTRACT Objective To explore the motivations and expectations of the users of the Program for Healthy Centers in the Autonomous City of Buenos Aires and to evaluate its potential health impact. Methods In-depth interviews were conducted (n = 34) and a self-administered survey was sent to users of the program (n = 605). An epidemiological model was developed to estimate the impact of the program on cardiovascular events (CVE) and disability-adjusted life years (DALYs). Results The main motivating factors for using the healthy centers were geographic and economic accessibility (free services) and satisfaction with the care received. 14.4% (95% CI, 10.3-18.5%) of hypertensive users and 24.8% (95% CI, 17.6-32.0%) of diabetic users reported having learned of their altered values in the healthy center. More than half of the respondents reported some improvement in their knowledge about the benefits of physical activity and healthy eating; this was more frequent among those who were younger, of lower educational level, users of the public health system, users of a healthy center in the South zone and those who had a cardiometabolic risk factor (p<0.05). It was estimated that the healthy centers would prevent 12.5 cardiovascular and cerebrovascular events per year in the assisted population (4.75 events/100 000) and 47.75 DALYs due to these causes. Conclusions The healthy centers are a favorable space for the implementation of health promotion and prevention actions, contributing to the detection of and facilitating the monitoring of risk factors, with a potential to prevent cardiovascular events and its consequences.

RESUMO Objetivo Explorar as motivações e expectativas dos usuários do Programa Estações Saudáveis na Cidade Autônoma de Buenos Aires e avaliar seu impacto potencial na saúde. Métodos Foram realizadas entrevistas em profundidade (n = 34) e uma pesquisa auto-administrada (n = 605) a usuários do programa. Um modelo epidemiológico foi desenvolvido para estimar o impacto do programa em eventos cardiovasculares e anos de vida ajustados por incapacidade (DALY). Resultados Os principais fatores motivadores para o uso do estações saudáveis foram a acessibilidade geográfica, econômica (serviços gratuitos) e a satisfação com o atendimento recebido. 14,4% (intervalo de confiança de 95% [IC95%] 10,3-18,5%) de usuários hipertensos e 24,8% (IC95% 17,6-32,0%) dos diabéticos relataram ter aprendido sobre seus valores alterados na estação saudável. Mais da metade dos entrevistados relataram alguma melhora no conhecimento sobre os benefícios da atividade física e da alimentação saudável, com maior freqüência entre os mais jovens, de menor escolaridade, usuários do sistema público de saúde, usuários de estações saudáveis na zona sul e aqueles que apresentaram algum fator de risco cardiometabólico (p<0,05). Estimou-se que, devido à existência de estações saudáveis, 12,5 eventos cardiovasculares e cerebrovasculares por ano seriam evitados na população atendida (4,75 eventos/100 000) e 47,75 DALY por essas causas. Conclusões As estações saudáveis são um espaço propício para a implementação de ações de promoção e prevenção da saúde, contribuindo para a detecção e facilitação do monitoramento dos fatores de risco, com potencial para prevenir os eventos cardiovasculares e suas consequências.

Cardiovascular Disease and Health Care System Impact on Functionality and Productivity in Argentina: A Secondary Analysis.

OBJECTIVES: To examine the impact of cardiovascular disease (CVD) events on patient functionality and productivity on the basis of patient use of public or social/private institution health care. METHODS: A secondary analysis was conducted of data drawn from records of Argentinian patients, 3 to 15 months posthospitalization after a CVD event, who had originally participated in a multicountry, cross-sectional study assessing the microeconomic impact of a CVD event. Respondents were stratified according to their use of health care institution (public or social/private). Among these groups, pre- and post-CVD event changes in functionality and productivity were compared. RESULTS: Participants' (N = 431) mean age was 56.5 years, and 73.5% were men. Public sector patients reported significantly higher rates of decline in ability to perform moderate activities (P < 0.05), a greater decrease in time spent at work (P < 0.01), a greater limit in the type of work-related activities (P < 0.01), and a higher rate of emotional problems (P < 0.01). Having health insurance (private or social) (odds ratio [OR] = 0.55; 95% confidence interval [CI] 0.35-0.85; P < 0.01) and a higher income (OR = 0.99; 95% CI 0.99-0.99; P < 0.01) were inversely and significantly associated with loss of productivity. Cerebrovascular disease (OR = 2.55; 95% CI 1.42-4.60; P < 0.01) was also significantly associated with productivity loss. CONCLUSIONS: In Argentina, patients receiving care in the public sector experienced a greater impact on functionality and productivity after their hospitalization for a CVD event. Lack of insurance, low income, and cerebrovascular disease event were the major determinants of productivity loss. Further investigation is needed to better understand contributors to these differences.

Carga de enfermedad por tabaquismo e impacto potencial del incremento de precios de cigarrillos en el Perú / Burden of smoking-related disease and potential impact of cigarette price increase in Peru

RESUMEN Objetivos . Estimar la carga de enfermedad asociada al tabaquismo y evaluar el potencial impacto económico y en salud del aumento de los impuestos a los cigarrillos en el Perú. Materiales y métodos. Mediante un modelo de microsimulación se estimó el impacto en mortalidad, calidad de vida y costos atribuibles al tabaquismo por enfermedad cardiaca y cerebrovascular, enfermedad pulmonar obstructiva crónica, neumonía, cáncer de pulmón y otras nueve neoplasias. Se evaluaron tres escenarios de aumento de impuestos. Resultados . Un total anual de 16 719 muertes, 6926 diagnósticos de cáncer, 7936 accidentes cerebrovasculares y 7548 hospitalizaciones por enfermedad cardiovascular se pueden atribuir al tabaquismo en Perú. Asimismo, se pierden 396 069 años de vida por muerte prematura y discapacidad cada año, y el costo de tratar los problemas de salud ocasionados por el tabaco asciende a 2500 millones de soles (PEN 2015). Actualmente, los impuestos al tabaco llegan a cubrir solamente el 9,1% de dicho gasto. Un incremento del 50% en el precio de los cigarrillos podría evitar 13 391 muertes, 6210 eventos cardiovasculares y 5361 nuevos cánceres en los próximos diez años, y representaría un beneficio económico de 3145 millones (PEN) por ahorro de costos sanitarios y aumento de la recaudación impositiva. Conclusiones . La carga de enfermedad y el costo para el sistema de salud asociados al tabaquismo son elevados en Perú. Incrementar los impuestos al cigarrillo podría derivar en importantes beneficios para el país, tanto sanitarios como económicos.

ABSTRACT Objectives . To calculate the burden of smoking-related disease and evaluate the potential economic and health impact of tax-induced cigarette price increase in Peru. Materials and methods. A microsimulation model was used to estimate smoking-attributable impact on mortality, quality of life, and costs associated with heart and cerebrovascular disease, chronic obstructive pulmonary disease, pneumonia, lung cancer, and another nine cancers. Three scenarios, involving increased taxes, were evaluated. Results . A yearly total of 16,719 deaths, 6,926 cancer diagnoses, 7,936 strokes, and 7,548 hospital admissions due to cardiovascular disease can be attributed to smoking in Peru. Similarly, 396,069 years of life are lost each year from premature death and disability, and the cost of treating smoking-attributable health issues rises to 2,500 million soles (PEN 2015). Currently, taxes on tobacco cover only 9.1% of this expense. If cigarette prices were to increase by 50% over the next 10 years, 13,391 deaths, 6,210 cardiovascular events, and 5,361 new cancers could be prevented, representing an economic benefit of 3,145 million (PEN) in savings in health costs and increases in tax revenues. Conclusions . Smoking-attributable burden of disease and costs to the health system are very high in Peru. Higher cigarette taxes could have substantial health and economic benefits for the country.

[Burden of smoking-related disease and potential impact of cigarette price increase in Peru]. / Carga de enfermedad por tabaquismo e impacto potencial del incremento de precios de cigarrillos en el Perú.

OBJECTIVES: . To calculate the burden of smoking-related disease and evaluate the potential economic and health impact of tax-induced cigarette price increase in Peru. MATERIALS AND METHODS.: A microsimulation model was used to estimate smoking-attributable impact on mortality, quality of life, and costs associated with heart and cerebrovascular disease, chronic obstructive pulmonary disease, pneumonia, lung cancer, and another nine cancers. Three scenarios, involving increased taxes, were evaluated. RESULTS: . A yearly total of 16,719 deaths, 6,926 cancer diagnoses, 7,936 strokes, and 7,548 hospital admissions due to cardiovascular disease can be attributed to smoking in Peru. Similarly, 396,069 years of life are lost each year from premature death and disability, and the cost of treating smoking-attributable health issues rises to 2,500 million soles (PEN 2015). Currently, taxes on tobacco cover only 9.1% of this expense. If cigarette prices were to increase by 50% over the next 10 years, 13,391 deaths, 6,210 cardiovascular events, and 5,361 new cancers could be prevented, representing an economic benefit of 3,145 million (PEN) in savings in health costs and increases in tax revenues. CONCLUSIONS: . Smoking-attributable burden of disease and costs to the health system are very high in Peru. Higher cigarette taxes could have substantial health and economic benefits for the country.

Association between socioeconomic status, type 2 diabetes and its chronic complications in Argentina.

AIM: To compare the socioeconomic status (SES) of people with type 2 diabetes (T2DM) in Argentina (Córdoba) with and without major chronic complications of diabetes, with that recorded in persons without diabetes matched by age and gender. METHODS: For this descriptive and analytic case-control study, potential candidates were identified from the electronic records of one institution of the Social Security System of the city of Córdoba. We identified and recruited 387 persons each with T2DM with or without chronic complications and 774 gender- and age-matched persons without T2DM (recruitment rate, 83%). Data were obtained by telephone interviews and supplemented with data from the institution's records. Group comparisons were performed with parametric or non-parametric tests as appropriate. We used ordinary least squares to regress household income and the difference between income and household expenses on diabetes status, age, sex, education and body mass index. RESULTS: Persons with T2DM, particularly those with complications, reported fewer years of general education (13.6±4.2 years vs. 12.2±4.4 years), a lower percentage of full time jobs (43.0% vs. 26.9%), lower salaries and monthly household income among those with full-time jobs (> 5000 ARG$: 52.6% vs. 24.5%), and a higher propensity to spend more money than they earned (expenditure/income ratio≥1: 10.2% vs. 16.0%). The percentage of unmarried people was also higher among people with type 2 diabetes (7.0% vs. 10.9%). CONCLUSION: T2DM and the development of its complications are each positively associated with lower SES and greater economic distress in Argentina.

The burden of diabetes in Argentina.

OBJECTIVE: To measure the economic burden of diabetes in Argentina by age, gender and region for the year 2005, in disability-adjusted life years (DALYs). METHODS: DALYs were estimated by the sum of years of life lost due to premature death (YLL) and years of life lived with disability (YLD). RESULTS: In the population studied (20 to 85 years), the burden of diabetes without complications was 1.3 million DALYs, 85% of which were caused by disabilities. Whereas mortality rates (YLL) increased as a function of age, YLD showed the opposite relationship. Women had higher burden of disease values, represented by 51 and 61% of YLL and YLD, respectively, independently of age. CONCLUSIONS: Our results demonstrate that disabilities are a key component of diabetes burden; its regular and systematic estimation would allow to design effective prevention strategies, to assess the impact of their implementation and to optimize resource allocation based on objective evidence.

A Comparison of 1-Year Treatment Costs in Patients with Type 2 Diabetes Following Initiation of Insulin Glargine or Insulin Detemir in Argentina.

OBJECTIVE: To estimate and compare type 2 diabetes mellitus treatment costs in insulin-naive patients following initiation of therapy with either insulin glargine (IG) or insulin detemir (ID) over 1-year time horizon from a payers' perspective in Argentina. METHODS: We used a pharmacoeconomic model based on a randomized trial comparing IG and ID (Rosenstock J, Davies M, Home PD, et al. A randomised, 52-week, treat-to-target trial comparing insulin detemir with insulin glargine when administered as add-on to glucose-lowering drugs in insulin-naive people with type 2 diabetes. Diabetologia 2008;51:408-16) and Argentinean sources. Clinical, resource use, and cost data were combined to estimate direct medical costs (insulin, test strips, and needles) during the first year. Price per international unit of insulin is similar for IG and ID in the local market. Deterministic analysis was performed on insulin unit cost and probabilistic sensitivity analyses on clinical, resource use, and unit costs to evaluate contribution to variance on the difference in total annual treatment cost. RESULTS: Annual mean treatment cost (Argentinean pesos 2013) was AR $6229 for IG and AR $9257 for ID, showing 33% total cost reduction with IG (AR $3028; exchange rate US $1.00 = AR $5.30). Probabilistic sensitivity analysis showed that IG was cost saving in 88% of the simulations. The most influential parameter was the difference in insulin dose requirements. Threshold analysis showed that if the unit price of ID is reduced by 43%, ceteris paribus, the total annual costs per person for both insulin regimens would be the same. CONCLUSIONS: From a payer's perspective in Argentina, cost savings related to the use of IG represented one third of total treatment costs. Sensitivity analyses confirmed the robustness of these results.

Diabetes in Argentina: cost and management of diabetes and its complications and challenges for health policy.

BACKGROUND: Diabetes is an expensive disease in Argentina as well as worldwide, and its prevalence is continuously rising affecting the quality of life of people with the disease and their life expectancy. It also imposes a heavy burden to the national health care budget and on the economy in the form of productivity losses. AIMS: To review and discuss a) the reported evidence on diabetes prevalence, the degree of control, the cost of care and outcomes, b) available strategies to decrease the health and economic disease burden, and c) how the disease fits in the Argentinian health care system and policy. Finally, to propose evidence-based policy options to reduce the burden of diabetes, both from an epidemiological as well as an economic perspective, on the Argentinian society. The evidence presented is expected to help the local authorities to develop and implement effective diabetes care programmes. METHODOLOGY: A comprehensive literature review was performed using databases such as MEDLINE, EMBASE and LILACS (Latin American and Caribbean Health Sciences). Literature published from 1980 to 2011 was included. This information was complemented with grey literature, including data from national and provincial official sources, personal communications and contacts with health authorities and diabetes experts in Argentina. RESULTS: Overall diabetes prevalence increased from 8.4% in 2005 to 9.6% 2009 at national level. In 2009, diabetes was the seventh leading cause of death with a mortality rate of 19.2 per 100,000 inhabitants, and it accounted for 1,328,802 DALYs lost in the adult population, mainly affecting women aged over fifty. The per capita hospitalisation cost for people with diabetes was significantly higher than for people without the disease, US$ 1,628 vs. US$ 833 in 2004. Evidence shows that implementation of combined educative interventions improved quality of care and outcomes, decreased treatment costs and optimised the use of economic resources. CONCLUSIONS: Based on the evidence reviewed, we believe that the implementation of structured health care programmes including diabetes education at every level, could improve quality of care as well as its clinical, metabolic and economic outcomes. If implemented across the country, these programmes could decrease the disease burden and optimise the use of human and economic resources.

Treatment of type 2 diabetes with saxagliptin: a pharmacoeconomic evaluation in Argentina.

BACKGROUND: The increasing prevalence of diabetes and its inadequate management results in a heavy burden of the disease for the patients, the health and the productive system and the overall community. Consequently, it is necessary to have new effective drugs to treat people with diabetes to decrease such burden. DPP-4 inhibitors can help to cope with this demand, but its usage is challenged by its apparent high cost. The aim of the current study was to compare a simulated cost-effectiveness ratio of metformin (MET) plus one drug of the DPP-4 inhibitors family, saxagliptin (SAXA) or sulfonylurea (SU) treatment during a 20-year period, from the perspective of the social security system, in a cohort of people with Type 2 diabetes (T2DM) who did not attain glycosylated hemoglobin treatment target values only with MET. METHODS: A discrete event simulation model (Cardiff diabetes model) based on UKPDS 68 was used to simulate disease progression and to estimate the economic and health treatment consequences in people with T2DM. The clinical efficacy parameters for SAXA administration were obtained from the literature; local standard costs were considered for drug acquisition, adverse events (AEs), and micro/macrovascular complications. Costs were expressed in US dollars (2009) with an annual 3.5% discount and a 20-year time horizon. RESULTS: The SAXA + MET treated group had a lower number of non-fatal events than the SU + MET treated group. The model also predicted a lower number of fatal macrovascular events for the SAXA + MET group (149.6 vs. 152.8). The total cost of the SAXA + MET cohort was 15% higher than that of the SU + MET cohort. Treatment with SAXA + MET resulted in a higher number of quality-adjusted life years (QALYs) (9.54 vs. 9.32) and life-years gained (LYGs) (20.84 vs. 20.76) compared to those treated with SU + MET. The incremental cost per QALY and LYG gained was $7,374 and $20,490, respectively. CONCLUSIONS: According to the criteria proposed by the Commission on Macroeconomics and Health, the use of the combination SAXA + MET is highly cost-effective in Argentina.

Evaluación económica del tratamiento de diabetes tipo 2 con saxagliptina en Colombia / Economic evaluation of type 2 diabetes treatment with saxagliptin in Colombia

Objetivo: Determinar la relación costo efectividad incremental del agregado de saxagliptina o sulfonilureas en Colombia a personas con DMT2 que no logran alcanzar metas glucémicas con metformina, durante un período máximo de 20 años. Metodología: Se realizó un estudio de costo efectividad, utilizando un modelo de simulación de eventos discretos con incremento de tiempo fijo (Diabetes Cardiff Model). Las características de la cohorte de pacientes y el perfil de eficacia para cada tratamiento se obtuvieron de la literatura. El costo de los medicamentos se obtuvo de SISMED y Farmaprecios. Los costos de los eventos macro y microvasculares se basaron en el POS, Manual Tarifario SOAT y consulta con experto local. La tasa de descuento en costos y beneficios fue 3,5 por ciento. Resultados: En el grupo tratado con saxagliptina registramos menos eventos fatales y no fatales y menos episodios de hipoglucemia. En ambas estrategias los mayores costos correspondieron a los medicamentos, seguidos por los asociados al tratamiento del infarto de miocardio. El costo incremental de la terapia con saxagliptina fue de US$ 555.552 a 20 años. El tratamiento con saxagliptina redundó en un mayor número de Años de Vida Ajustados por Calidad (AVAC) y Años de Vida Ganados (AVG), respecto al obtenido con sulfonilureas. El costo por AVAC fue de US$ 2.190. Los resultados de costo efectividad fueron robustos al análisis de sensibilidad. Conclusión: El agregado de saxagliptina a pacientes que no logran un control glucémico adecuado con metformina, es muy costo efectiva comparada con el agregado de sulfonilureas.

Objective: To determine in Colombia, the cost effectiveness ratio of the saxagliptin or sulphonylureas addition to patients with T2DM who fail to achieve glycemic goals with metformin, for a maximum period of 20 years. Methods: We performed a cost effectiveness analysis, using a discrete event simulation model with fixed time step (Cardiff Diabetes Model). The characteristics of the cohort of patients and efficacy profile for each treatment were obtained from the literature. The cost of medication was obtained from SISMED and Farmaprecios. The costs of macro and microvascular events were based on POS tariffs, SOAT Manual and consultation with local expert. The discount rate on costs and benefits was 3.5 percent. Results: The group treated with saxagliptin had fewer fatal and nonfatal events and fewer episodes of hypoglycemia than the one with sulfonylureas. In both strategies the higher cost corresponds to the drugs, followed by those associated with the treatment of myocardial infarction. The incremental cost of saxagliptin therapy was US$ 555.552 to 20 years. Saxagliptin treatment resulted in a greater number of quality-adjusted life year (QALYs) and life-years gained (LYG) than that obtained with sulfonylureas. The cost per QALY was US$ 2,190. Cost-effectiveness results were robust to sensitivity analysis. Conclusion: Addition of saxagliptin to patients who do not achieve adequate glycemic control with metformin, is highly cost-effective compared with the addition of sulphonylureas.

Evaluación de los determinantes socioeconómicos de los factores de riesgo cardiovascular en Argentina: un análisis multinivel / Evaluation of the socioeconomic determinants of cardiovascular risk factors in Argentina: a multilevel analysis

INTRODUCCION: La mayor parte de la carga de enfermedades cardiovasculares está relacionada con factores de riesgo modificables y podría reducirse mediante intervenciones poblacionales y clínicas.OBJETIVO: Generar conocimientos útiles para el diseño de estrategias de prevención, control y tratamiento de los factores de riesgo cardiovascular (FRCV) y promover su utilización para la toma de decisiones basadas en evidencia, tanto a nivel nacional como provincial.METODOS: Mediante modelos de regresión logística multinivel, se determinó el impacto de factores sociodemográficos y económicos sobre la presencia de hipertensión, colesterol elevado, diabetes, obesidad y tabaquismo.RESULTADOS: Los hombres y las personas mayores de 50 años fueron los grupos más afectados. En general, le hecho de tener un mayor nivel educativo redujo las posibilidades de presentar FRCV. La presencia de ocupación aumentó las posibilidades de presentar FRCV respecto al hecho de estar desocupado. Este efecto presentó un amplio rango (6 a 64%) para distintos tipos de ocupación. El impacto del ingreso fue contradictorio. La presencia de cobertura aumentó en general las posibilidades de presentar FRCV entre un 4 y 53% respecto a quienes no contaban con esa cobertura. Pocas variables de nivel provincial resultaron significativas: índice de desarrollo humano, gasto público en salud per cápita y, como proporción del gasto público total, proporción de médicos y de hogares pobres.CONCLUSIONES: Las características demográficas y socioeconómicas de los individuos inciden en la presencia de FRCV. El hecho de vivir en diferentes provincias influye a la hora de identificar los determinantes demográficos y socioeconómicos de la presencia de FRCV.

INTRODUCTION: Most of the burden of cardiovascular diseases is associated with modifiable risk factors that could be reduced through population and clinical interventions.OBJECTIVE: To generate knowledge and tools in order to design strategies for prevention, control and treatment of cardiovascular risk factors (CVRF) and promote their use for making decisions based on evidence, both at national and provincial levels.METHODS: Multilevel logistic regression models determined the impact of sociodemographic and economic factors on the presence of hypertension, high cholesterol, diabetes, obesity and smoking.RESULTS: Men and people over 50 were the most affected groups. In general, having a higher level of education reduced the chances of cardiovascular risk factors. The presence of occupation increased the chances of CVRF with respect to being unemployed. This effect showed a wide range (6 to 64%) for different types of occupation. The impact of income was contradictory. The presence of health insurance increased between 4 and 53% the chances of CVRF, in comparison with people who did not have the insurance. Few expenditure per capita and as a proportion of total public expenditure, percentage of physicians and poor households.CONCLUSIONS: The demographic and socioeconomic characteristics of individuals affect the presence of cardiovascular risk factors. Living in different provincies has an effect when trying to identify the demographic and socioeconomic determinants of cardiovascular risk factors.

Evaluación de los determinantes socioeconómicos de los factores de riesgo cardiovascular en Argentina: un análisis multinivel / Evaluation of the socioeconomic determinants of cardiovascular risk factors in Argentina: a multilevel analysis

INTRODUCCION: La mayor parte de la carga de enfermedades cardiovasculares está relacionada con factores de riesgo modificables y podría reducirse mediante intervenciones poblacionales y clínicas.OBJETIVO: Generar conocimientos útiles para el diseño de estrategias de prevención, control y tratamiento de los factores de riesgo cardiovascular (FRCV) y promover su utilización para la toma de decisiones basadas en evidencia, tanto a nivel nacional como provincial.METODOS: Mediante modelos de regresión logística multinivel, se determinó el impacto de factores sociodemográficos y económicos sobre la presencia de hipertensión, colesterol elevado, diabetes, obesidad y tabaquismo.RESULTADOS: Los hombres y las personas mayores de 50 años fueron los grupos más afectados. En general, le hecho de tener un mayor nivel educativo redujo las posibilidades de presentar FRCV. La presencia de ocupación aumentó las posibilidades de presentar FRCV respecto al hecho de estar desocupado. Este efecto presentó un amplio rango (6 a 64%) para distintos tipos de ocupación. El impacto del ingreso fue contradictorio. La presencia de cobertura aumentó en general las posibilidades de presentar FRCV entre un 4 y 53% respecto a quienes no contaban con esa cobertura. Pocas variables de nivel provincial resultaron significativas: índice de desarrollo humano, gasto público en salud per cápita y, como proporción del gasto público total, proporción de médicos y de hogares pobres.CONCLUSIONES: Las características demográficas y socioeconómicas de los individuos inciden en la presencia de FRCV. El hecho de vivir en diferentes provincias influye a la hora de identificar los determinantes demográficos y socioeconómicos de la presencia de FRCV.

INTRODUCTION: Most of the burden of cardiovascular diseases is associated with modifiable risk factors that could be reduced through population and clinical interventions.OBJECTIVE: To generate knowledge and tools in order to design strategies for prevention, control and treatment of cardiovascular risk factors (CVRF) and promote their use for making decisions based on evidence, both at national and provincial levels.METHODS: Multilevel logistic regression models determined the impact of sociodemographic and economic factors on the presence of hypertension, high cholesterol, diabetes, obesity and smoking.RESULTS: Men and people over 50 were the most affected groups. In general, having a higher level of education reduced the chances of cardiovascular risk factors. The presence of occupation increased the chances of CVRF with respect to being unemployed. This effect showed a wide range (6 to 64%) for different types of occupation. The impact of income was contradictory. The presence of health insurance increased between 4 and 53% the chances of CVRF, in comparison with people who did not have the insurance. Few expenditure per capita and as a proportion of total public expenditure, percentage of physicians and poor households.CONCLUSIONS: The demographic and socioeconomic characteristics of individuals affect the presence of cardiovascular risk factors. Living in different provincies has an effect when trying to identify the demographic and socioeconomic determinants of cardiovascular risk factors.

[Budgetary impact analysis in health: update with a model using a generic approach]. / El análisis de impacto presupuestario en salud: puesta al día con un modelo de abordaje genérico.

Budgetary Impact Analysis (BIA) applied to health care can be defined as the estimate of the net financial costs that a given intervention would represent for a health care institution given the case it was covered. Routinely, BIAs are used to decide the inclusion or exclusion of drugs in therapeutic schemes; actually, the increased use of BIAs have raised awareness about the fact that health economic evaluations represent a partial view in the analysis of the consequences of incorporating health technologies. This paper seeks to identify the determinants and components of BIA, and to describe the development of a spreadsheet model that enables us to assess the Budget impact of any health technology and perform estimations with differing degrees of complexity. Its design explicitly adapts to the user skills and gaps in information, thus seeking to promote the development of these tools in the management fields in our countries.

El análisis de impacto presupuestario en salud: puesta al día con un modelo de abordaje genérico / Budgetary impact analysis in health: update with a model using a generic approach

El Análisis de Impacto Presupuestario (AIP) en el campo de la salud puede ser definido como la estimación de los costos financieros netos que le representarían a una institución dar cobertura a una determinada intervención. En la práctica, los AIP se utilizan frecuentemente para decidir la inclusión o exclusión de medicamentos en formularios terapéuticos y notoriamente han obligado a reconocer que las Evaluaciones Económicas representan una mirada parcial en el análisis de las consecuencias de la incorporación de tecnologías sanitarias. Este trabajo procura identificar los determinantes y componentes de los análisis de impacto presupuestario, y a partir de ello describir el desarrollo de un modelo creado en una planilla de cálculo que permite considerar cualquier tecnología sanitaria y obtener estimaciones con diferentes grados de complejidad. Su diseño incorpora de forma explícita las habilidades del usuario y las deficiencias de información, buscando a su vez promover el desarrollo de estas herramientas en los ámbitos de gestión de nuestros países.

Budgetary Impact Analysis (BIA) applied to health care can be defined as the estimate of the net financial costs that a given intervention would represent for a health care institution given the case it was covered. Routinely, BIAs are used to decide the inclusion or exclusion of drugs in therapeutic schemes; actually, the increased use of BIAs have raised awareness about the fact that health economic evaluations represent a partial view in the analysis of the consequences of incorporating health technologies. This paper seeks to identify the determinants and components of BIA, and to describe the development of a spreadsheet model that enables us to assess the Budget impact of any health technology and perform estimations with differing degrees of complexity. Its design explicitly adapts to the user skills and gaps in information, thus seeking to promote the development of these tools in the management fields in our countries.

Hospitalization costs for heart failure in people with type 2 diabetes: cost-effectiveness of its prevention measured by a simulated preventive treatment.

OBJECTIVES: To estimate the cost-consequence of interventions to prevent hospitalizations for heart failure (HF) in people with type 2 diabetes. METHODS: In HF events (63) from type 2 diabetes-related hospitalizations (N = 462) recorded in an Argentine hospital (March 2004-April 2005), we verified 1) the presence of one metabolic HF predictor (glycosylated hemoglobin [HbA1c] value) before hospitalization; and 2) in a simulation model, the resources needed for its prevention controlling such predictor during 6 months before and after the event. Sensitivity analysis of HF risk reduction, hospitalization cost, and cost of different treatments to achieve HbA1c 7% or less was performed with a Monte Carlo simulation (10,000 iterations). RESULTS: HF represented 14% of hospitalizations, with a 44% rehospitalization rate for the same cause. Due to the total estimated cost for an HF hospitalization event was $437.31, the prevention attained using our simulated treatment was $2326.51. The number needed to treat to prevent an HF event under any of the proposed alternatives to reduce HbA1c would be 3.57 (95% confidence interval 2.00-16.67). The additional cost of the simulated treatment versus the real one oscillates between $6423.91 and $8455.68. CONCLUSIONS: HbA1c control to reduce the number of HF events would be economically beneficial for health care payers.

A cross-sectional study of the microeconomic impact of cardiovascular disease hospitalization in four low- and middle-income countries.

OBJECTIVE: To estimate individual and household economic impact of cardiovascular disease (CVD) in selected low- and middle-income countries (LMIC). BACKGROUND: Empirical evidence on the microeconomic consequences of CVD in LMIC is scarce. METHODS AND FINDINGS: We surveyed 1,657 recently hospitalized CVD patients (66% male; mean age 55.8 years) from Argentina, China, India, and Tanzania to evaluate the microeconomic and functional/productivity impact of CVD hospitalization. Respondents were stratified into three income groups. Median out-of-pocket expenditures for CVD treatment over 15 month follow-up ranged from 354 international dollars (2007 INT$, Tanzania, low-income) to INT$2,917 (India, high-income). Catastrophic health spending (CHS) was present in >50% of respondents in China, India, and Tanzania. Distress financing (DF) and lost income were more common in low-income respondents. After adjustment, lack of health insurance was associated with CHS in Argentina (OR 4.73 [2.56, 8.76], India (OR 3.93 [2.23, 6.90], and Tanzania (OR 3.68 [1.86, 7.26] with a marginal association in China (OR 2.05 [0.82, 5.11]). These economic effects were accompanied by substantial decreases in individual functional health and productivity. CONCLUSIONS: Individuals in selected LMIC bear significant financial burdens following CVD hospitalization, yet with substantial variation across and within countries. Lack of insurance may drive much of the financial stress of CVD in LMIC patients and their families.