Cost-effectiveness of early intervention in psychosis in low- and middle-income countries: economic evaluation from São Paulo, Brazil.

AIMS: The effectiveness and cost-effectiveness of early intervention for psychosis (EIP) services are well established in high-income countries but not in low- and middle-income countries (LMICs). Despite the scarcity of local evidence, several EIP services have been implemented in LMICs. Local evaluations are warranted before adopting speciality models of care in LMICs. We aimed to estimate the cost-effectiveness of implementing EIP services in Brazil. METHODS: A model-based economic evaluation of EIP services was conducted from the Brazilian healthcare system perspective. A Markov model was developed using a cohort study conducted in São Paulo. Cost data were retrieved from local sources. The outcome of interest was the incremental cost-effectiveness ratio (ICER) measured as the incremental costs over the incremental quality-adjusted life-years (QALYs). Sensitivity analyses were performed to test the robustness of the results. RESULTS: The study included 357 participants (38% female), with a mean (SD) age of 26 (7.38) years. According to the model, implementing EIP services in Brazil would result in a mean incremental cost of 4,478 Brazilian reals (R$) and a mean incremental benefit of 0.29 QALYs. The resulting ICER of R$ 15,495 (US dollar [USD] 7,640 adjusted for purchase power parity [PPP]) per QALY can be considered cost-effective at a willingness-to-pay threshold of 1 Gross domestic product (GDP) per capita (R$ 18,254; USD 9,000 PPP adjusted). The model results were robust to sensitivity analyses. CONCLUSIONS: This study supports the economic advantages of implementing EIP services in Brazil. Although cultural adaptations are required, these data suggest EIP services might be cost-effective even in less-resourced countries.

The role of ageing in the wish to be dead: disentangling age, period and cohort effects in suicide ideation in European population.

AIMS: To investigate potential age, period and birth cohort effects in the prevalence of suicide ideation in European ageing population. METHODS: A total of 50 782 community-dwelling adults (aged + 50) from 20 different European countries were collected in the Survey Health Ageing and Retirement study. A multilevel logistic regression model of repeated measures was modelled to assess the effects of age and other variables, including the variability of observations over three levels: birth cohort groups, time period assessment and individual differences. RESULTS: The larger effect of variability was attributed to individual-level factors (57.8%). Youngest-old people (65-79 years) showed lower suicide ideation than middle-aged people (50-64 years). No significative differences were found for suicide ideation between middle-aged people and oldest-old (80 + years). Only 0.85% and 0.13% of the total variability of suicide ideation accounted for birth cohort and period effects, respectively. Cohorts born between 1941 and 1944 possessed the lowest estimates of suicide ideation. Conversely, suicide ideation started to rise with post-War generations and reached a significant level for people born from 1953-1957 to 1961-1964. Regarding the time period, participants assessed in 2006-2007 showed a lower likelihood of suicide ideation. The rest of the cohorts and period groups did not show any significant effect on the prevalence of suicide ideation. CONCLUSIONS: Our results suggest that age and suicide ideation relationship is not linear in middle and older age. The European Baby boomers born from 50s to mid-60s might report higher suicide ideation than their ancestors. This scenario would imply a greater need for mental healthcare services for older people in the future.

Stability of clinically relevant depression symptoms in old-age across 11 cohorts: a multi-state study.

AIMS: To study the temporal dynamics of depression symptom episodes in old-age and the related influence of risk factors. METHODS: Data from 41 362 old adults (54.61% women; mean age = 75.30, SD = 6.20) from the Ageing Trajectories of Health - Longitudinal Opportunities and Synergies (ATHLOS) project were used. Depressive symptoms were followed over an 18-year period. A multi-state model, comprising three statuses (no depression, new clinically relevant episode of symptoms and episode persistence), was fitted. Multinomial regression was used to study the role of risk factors in status transition. RESULTS: Almost 85% of participants showed no depression, but prevalence became lower over time (B = -0.25, P < 0.001). New episode point prevalence was over 5.30% with a significant probability of moving to persistence status (transition probability = 0.27). Episode persistence became evident in 9.86% of episode status transitions, with increasing rate over time (B = 0.54, P < 0.01). Loneliness was proven to be the strongest predictor of episode emergence (OR = 17.76) and persistence (OR = 5.93). CONCLUSIONS: The course of depression tends to become chronic and unremitting in old-age. This study may help to plan interventions to tackle symptom escalation and risk factor influence.

Percepción de residentes de pediatría en cuanto a su formación en contenidos transversales. Investigación cualitativa con grupos focales / Perception of residents in pediatrics regarding their training in cross-curricular subjects. Qualitative research in focus groups

Introducción: Los programas de residencia médica son uno de los principales sistemas de formación de especialidades básicas y posbásicas. A partir del análisis "evaluación participativa" de la OPS en 2002 y el informe de la dra. M. Rosa Borrell en 2005, el Ministerio de Salud de la Nación definió bloques transversales en las bases curriculares. Los contenidos transversales abordan problemas centrales del campo de la salud y de la atención, comunes a todas las profesiones médicas. Contextualizan y determinan el ejercicio profesional. El propósito de este trabajo es contribuir a la evaluación del programa de residencias tomando como objeto de interés a los sujetos participantes de las residencias. Objetivo comprender las percepciones de los residentes de Pediatría del Hospital Garrahan sobre la formación en contenidos transversales. Población y métodos. 4 grupos focales, con 4-6 residentes de tercer y cuarto año de pediatría del Hospital Garrahan. Con ejes de discusión previamente planificados, con un tiempo de duración (120 minutos), en un ambiente no directivo, con múltiples disparadores. Análisis: los contenidos de los grupos focales se analizaron a través de la metodología de "teoría fundamentada en los datos" asistido por el programa ATLAS. Ti (versión 8). Resultados. Participaron 20 residentes, con una mediana de edad de 27 +/- 2 años. A partir de los tres ejes de discusión planificados para los grupos focales se elaboraron núcleos temáticos: normativo institucional, programa de formación, dinámicas de aprendizaje, sectores y climas de trabajo, el paciente y su familia, displicencia. En primer lugar, se reconocieron ingresando a una institución con normas de funcionamiento, en donde "la planta" se describió como la figura normativa predominante. En cuanto al programa de formación, hubo satisfacción con las capacidades alcanzadas. Sin embargo, se debatió si el perfil de profesional alcanzado permite reconocer determinantes de salud más allá de las comorbilidades estrictamente médicas. Surgieron problemáticas vinculadas a los límites del modelo médico hegemónico y la necesidad de nuevos enfoques de aprendizaje a través de la problematización del paciente en su contexto social. Definieron los casos clínicos como la mejor forma de abordar el conocimiento sobre un tema. Surgió espontáneamente el tema de la discriminación. Conclusión: a través de los grupos focales, como espacio de escucha activa de la experiencia cotidiana de trabajo de los residentes del Hospital Garrahan surgieron problemáticas vinculadas a los límites del modelo médico hegemónico y la necesidad de enfoques de aprendizaje a través de la problematización del paciente en su contexto social (AU)

Introduction: Medical residency programs are one of the main systems for the training in basic and post-basic specialties. Based on the "participatory evaluation" analysis by the PAHO in 2002 and the report by dr. M. Rosa Borrell in 2005, the National Ministry of Health defined cross-curricular groups to form the basis of the curriculum. The cross-curricular contents address core subjects in the health care field, common to all medical professions. These subjects contextualize and determine the professional practice. The aim of this study was to contribute to the evaluation of the residency program focusing on the participants in the residency programs. Objective: To assess the perceptions of the residents in Pediatric Hospital Garrahan regarding the training and crosscurricular contents. Population and methods: 4 focus groups, with 4-6 residents of the third and fourth year of Pediatrics at Garrahan Hospital using previously determined lines of discussion, in a time slot of 120 minutes, in a non-directive environment, with multiple triggers. Analysis: The contents of the focus groups were analyzed using the "grounded theory data" methodology supported by the ATLAS program, Ti (version 8). Results: 20 residents, with a median age of 27 +/- 2 years, participated in the program. Based on the three discussion lines planned for the focus groups, six core topics were developed: Institutional norms, training program, learning dynamics, sectors and work environments, the patients and their families, displeasure. In the first place, the subjects recognized they entered an institution with its proper norms, in which "the staff" describes itself as the predominant normative figures. Regarding the training program, subjects were satisfied with skills obtained. However, there was debate as to whether the professional profile achieved included knowledge on determining health factors beyond the strictly medical comorbidities. Issues came up related to the limits of the hegemonic model of the physician and the need for new learning targets through the problematization of the patient in his or her social context. Clinical cases were defined as the best way to approach the knowledge on this subject. The subject of discrimination came up spontaneously. Conclusion: Through focus groups, as an active listening space for the experience in the daily practice of the residents at Garrahan Hospital Garrahan, issues appeared related to the limits of the hegemonic model of the physician the need for new learning targets through the problematization of the patient in his or her social context (AU)

Evaluation of most frequent errors in daily compilation and use of a radiation treatment chart.

Between 1 March and 30 April (1994) we recorded the errors detected by the physician, the radiographer or the physicist during prescription, preparation and execution phases of 227 treatment plans. The radiation treatment modalities used were the following: (i) single or opposed fields, moulded or not; and (ii) multiple fields or kinetic techniques. The total number of sessions performed is 1613 with the cobalt unit and 2131 with the linear accelerator (total, 3744). The total number of wrong data is 155, consisting of 24/227 (10.5%) in compilation, 22/3744 (0.58%) in execution and 109/3744 (2.9%) in registration phases. The number of missing data is 140, consisting of 10/227 (4.4%) in compilation, 9/3744 (0.2%) in execution and 121/3744 (3.2%) in registration phases. Wrong data of compilation, even if in high rate (10.5%), were all found during the same compilation phase or at the first treatment, so that they did not alter the exactness of the treatment plan. Wrong and missing data, found in the registration phase (2.9% and 3.2%, respectively), depend on the repetition of daily treatment and on the registration of data on the chart after having digitized them on the display.