Bladder cancer trends and mortality in the brazilian public health system

ABSTRACT Introduction Considering the lack of data on BC trends in Brazilian population, mainly as a result of the difficulty on gathering data, the present manuscript provides an overview of bladder cancer incidence, hospitalization, mortality patterns and trends using the Brazilian Data Center for The Public Health System (DATASUS). Materials and Methods All hospital admissions associated with BC diagnosis (ICD-10 C67) between 2008 and 2017 were analyzed. Distributions according to year, gender, age group, ethnicity, death, length of hospital stay, and costs were evaluated. Demographic data was obtained from the last Brazilian national census. Results From 2008 to 2017 there were 119,058 public hospital admissions related to BC. Patients were mostly white males aged 60 to 79 years-old. Mortality rates for patients who have undergone surgery was 6.75% on average, being 7.38% for women and 6.49% for men. Mortality rates were higher when open surgeries were performed compared to endoscopic procedures (4.98% vs 1.18%). Considering only endoscopic procedures, mortality rates were three times higher after urgent surgeries compared to elective ones (2.6% vs 0.6%). Over the years the cystectomy/transurethral bladder resection (C/T) ratio significantly decreased in all Brazilian Regions. In 2008, the C/T ratio was 0.19, while in 2017 it reduced to 0.08. Conclusions Despite BC relatively low incidence, it still represents a significant social economic burden in Brazil, as it presents with recurrent episodes that might require multiple hospitalizations and surgical treatment. The set of data collected might suggest that population access to health care has improved between 2008-2017.

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.

Síndromes coronarios agudos en instituciones póblicas y no póblicas de Argentina / Acute coronary syndromes in public and non-public institutions of Argentina

El tratamiento del síndrome coronario agudo (SCA) puede diferir segó;ºn la cobertura de salud. El objetivo fue comparar características demográficas de pacientes con SCA atendidos en instituciones del sector pó;ºblico, o en el no-pó;ºblico de Argentina, las terapó;©uticas y su relació;n con los recursos de cada sector. Analizamos internaciones en instituciones de un registro nacional, voluntario, prospectivo y multicó;©ntrico. Entre marzo 2006 y mayo 2016 ingresaron 11 072 SCA en 64 instituciones, 39% pó;ºblicas (44% con laboratorio de hemodinamia) y 61% no pó;ºblicas (82% con hemodinamia). Los centros pó;ºblicos presentaron menos estructura y atendieron mayor proporció;n de SCA con elevació;n del segmento ST (SCACEST) (52.5% vs. 36.1%, p < 0.001). Los pacientes del sector pó;ºblico fueron más jó;venes, más frecuentemente hombres, fumadores, y menos dislipó;©micos. La proporció;n de reperfundidos entre SCA con elevació;n del ST (SCACEST) fue similar en ambos sectores. La utilizació;n de coronariografía en SCA sin elevació;n del ST (SCASEST) fue mayor en el sector pó;ºblico, cuyos pacientes presentaron más frecuentemente cambios electrocardiográficos y biomarcadores elevados. Un 80.2% de los SCA en instituciones pó;ºblicas y 90.1% en las no pó;ºblicas fueron incorporados por centros con hemodinamia. La disponibilidad de hemodinamia fue la variable más asociada a reperfusió;n entre SCACEST y al tratamiento invasivo entre SCASEST. Se demuestra la complejidad del análisis comparativo de sectores de salud, por la relevancia que adquieren los recursos instalados y las diferencias demográficas de la població;n, por encima de la simple diferencia de pertenecer al sistema pó;ºblico o al no pó;ºblico.

Treatment of acute coronary syndrome (ACS) may differ according to the health system coverage. The objective of this study was to evaluate demographic characteristics of patients with ACS assisted in public sector institutions compared to the non-public sector of Argentina, as well as the therapeutic and its relationship with the resources of each sector. We analyzed patients hospitalized in institutions of a national, voluntary, prospective and multicenter registry. Between March 2006 and May 2016, 11 072 ACSs were registered in 64 institutions, 39% public (44% have hemodynamic laboratory) and 61% non-public (82% with hemodynamic). Public centers presented less structure and assisted a higher proportion of ST elevation acute coronary syndrome (STE-ACS). (52.5% vs. 36.1%, p < 0.001). Public sector patients were younger, more frequently men, smokers, and less dyslipemics. The proportion of patients reperfused in the STE-ACS was similar in both sectors. The use of coronary angiography in non-ST elevation acute coronary syndrome (NSTE-ACS) was higher in the public sector, whose patients presented more frequently electrocardiographic changes and biomarker elevation. Considering all ACS, 80.2% of patients in public and 90.1% in non-public institutions were incorporated by haemodynamic centers. The availability of hemodynamics was the variable most associated with reperfusion in NSTE-ACS, and invasive treatment in NSTE-ACS. This research demonstrates the complexity of a comparative analysis of health sectors, due to the relevance acquired by the level of resources installed and the demographic differences of the inpatient population, above the simple difference of belonging to the public or non-public system.

AL amyloidosis in the Chilean public health system: a pending debt: multicenter study of the Chilean Monoclonal Gammopathies Cooperative Group / Amiloidosis AL en el sistema público de Chile: una deuda pendiente: estudio multicéntrico

ABSTRACT Background: Immunoglobulin light chain (AL) amyloidosis is a rare and underdiagnosed entity. Aim: To characterize patients with AL amyloidosis in Chilean public health centers. Material and Methods: We conducted a retrospective, multicenter study. Public centers of the Chilean Monoclonal Gammopathies Cooperative Group were asked to search for patients with AL amyloidosis in their databases. Epidemiological, clinical and laboratory characteristics were evaluated. Results: Forty-two patients aged 22 to 84 years were found. Twenty four percent had localized AL amyloidosis; 64% had a lambda light chain clone; 47% were associated with multiple myeloma and 9% with non-Hodgkin lymphoma. The most commonly involved organ was the kidney (76%). Serum free light chains were measured in 31% and an echocardiogram was performed in 74% of patients. Seventeen percent of patients received only palliative care, 17% were treated with bortezomib, 21% with thalidomide, and 40% with melphalan. No patient was transplanted. The mean overall survival (OS) of the group was 19 months. The 5-year OS was 28%. Conclusions: It is important to obtain these realistic, national data to initiate strategies to improve early diagnosis and proper management of this disease.

La amiloidosis AL es una entidad poco frecuente y subdiagnosticada. Mientras todo el mundo discute sobre las nuevas herramientas diagnósticas y terapéuticas, en Chile y en América Latina en general, estamos lejos de esa realidad. El objetivo del presente estudio fue caracterizar a los pacientes con amiloidosis AL en centros del sistema público de nuestro país. Se realizó un estudio retrospectivo, multicéntrico, descriptivo. Los centros públicos del grupo cooperativo hematológico chileno buscaron en sus bases de datos pacientes diagnosticados con amiloidosis AL. Se evaluaron las características epidemiológicas, clínicas y de laboratorio. La edad media fue de 65 años. A 24% de los pacientes se les diagnosticó amiloidosis AL localizada; 64% tuvo paraproteína con cadena ligera lambda; 47% se asoció con mieloma múltiple y 9% con linfoma no Hodgkin. El órgano afectado con mayor frecuencia fue el riñón (76%). Las cadenas ligeras libres de suero se realizaron en 31% y ecocardiograma en 74%. El 17% recibió solo cuidados paliativos, 17% recibió tratamiento con bortezomib, 21% con talidomida y 40% con melfalán. Ningún paciente fue trasplantado. La media de sobrevida global (SG) del grupo fue de 19 meses. La SG a 5 años fue de 28%. Es importante reportar estos resultados nacionales para iniciar estrategias que mejoren tanto el diagnóstico temprano como el tratamiento de esta patología. Por lo tanto, mejorar la sospecha diagnóstica es crucial.

Mexican ENARM: performance comparison of public vs. private medical schools, geographic and socioeconomic regions / ENARM: comparación del desempeño de escuelas de medicina públicas y privadas, regiones geográficas y socioeconómicas

Abstract: Objectives: This study aimed to compare the performance in the National Assessment for Applicants for Medical Residency (ENARM in spanish) of private versus public medical schools, geographic regions and socioeconomic levels by using three different statistical methods (summary measurements, the rate of change and the area under the receiver operator characteristics [AUROC]). These methods have not been previously used for the ENARM; however, some variations of the summary measurements have been reported in some USA assessments of medical school graduates. Materials and methods: Cross-sectional study based on historical data (2001-2017). We use summary measures and colour-filled map. The statistical analysis included Mann-Whitney U, Kruskal-Wallis, Spearman correlation coefficient (Rs), and linear regression. Results: A total of 113 medical schools were included in our analysis; 60 were public and 53 private. We found difference in the median of total scores for type of schools, MD= 54.07 vs. MD= 57.36,p= 0.011. There were also significant differences among geographic and socioeconomic regions (p<0.05). Conclusions: Differences exist in the total scores and percentage of selected test-takers between type of schools, geographic and socioeconomic regions. Higher scores are prevalent in the Northeast and Norwest regions. Additional research is required to identify factors that contribute to these differences. Unsuspected differences in examination scores can be unveiled using summary measures.

Resumen: Objetivo: Comparar el desempeño en el Examen Nacional de Aspirantes a Residencias Médicas (ENARM) de escuelas de medicina privadas y públicas, regiones geográficas y niveles socioeconómicos mediante el uso de tres métodos estadísticos diferentes (medidas de resumen, tasa de cambio y el área bajo las características del operador receptor [AUROC en inglés]). Estos métodos no han sido utilizados previamente para el ENARM; sin embargo, se han informado algunas variaciones de las mediciones de resumen en algunas evaluaciones de graduados de medicina de Estados Unidos. Material y métodos: Estudio transversal basado en datos históricos (2001-2017). Se usaron medidas de resumen y un mapa lleno de color. El análisis estadístico incluyó Mann Whitney U, Kruskal-Wallis y coeficiente de correlación de Spearman (Rs). Resultados: Se incluyeron 113 escuelas de medicina en el análisis; 60 eran públicas y 53 privadas. Se encontraron diferencias en la mediana de las puntuaciones totales para el tipo de escuelas, MD= 54.07 vs. MD= 57.36,p= 0.011. También hubo diferencias significativas entre las regiones geográficas y socioeconómicas (p<0.05). Conclusiones: Existen diferencias en los puntajes totales y el porcentaje de examinados seleccionados entre el tipo de escuelas, regiones geográficas y socioeconómicas. Las puntuaciones más altas prevalecen en las regiones noreste y noroeste. Se requieren investigaciones adicionales para identificar los factores que contribuyen a estas diferencias. Las diferencias insospechadas en los puntajes de los exámenes se pueden revelar usando medidas de resumen.

Disparities In The Use Of Drug-eluting Stents For Diabetic Patients With ST-elevation Acute Myocardial Infarction Assisted In the Public versus Private Network - VICTIM Register / Disparidades no Uso de Stents Farmacológicos para Pacientes Diabéticos com Infarto Agudo do Miocárdio com Supradesnivelamento do Segmento ST Assistidos na Rede Pública versus Privada - Registro VICTIM

Abstract Background: Primary angioplasty (PA) with placement of either bare metal or drug-eluting stents (DES) represents the main strategy in the treatment of ST-elevation myocardial infarction (STEMI). Diabetic patients, however, represent a special population in STEMI, with high rates of restenosis and unfavorable clinical outcomes, and with the use of DES, level of evidence A and indication class II, being indicated to reduce these damages. Objectives: To evaluate the DES rate of use in patients with STEMI and in the subgroup of diabetics assisted in the public versus private health network in Sergipe. Methods: This is a population-based, cross-sectional study with a quantitative approach using the data from the VICTIM Register. These were collected in the only four hospitals with capacity to perform PA in Sergipe, from December 2014 to March 2017. Results: A total of 707 patients diagnosed with STEMI were evaluated, of which 589 were attended at SUS and 118 at the private network. The use of DES in PA was lower in SUS compared to the private network in both the total sample (10.5% vs 82.4%, p<0.001) and in subgroup diabetic patients (8.7% vs 90.6%, p < 0.001), respectively. In all hypotheses tested, the level of significance was 5% (p < 0.05). Conclusions: The study reveals a disparity in the use of DES during the performance of PA between the public and private network, both in the total sample and the subgroup for diabetics, with lower rates for SUS users, demonstrating the challenges that need to be overcome in order to achieve quality improvements of the services provided.

Resumo Fundamento: A angioplastia primária (AP) com colocação de stent, seja ele convencional ou farmacológico, representa a principal estratégia no tratamento do infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST). Os pacientes diabéticos, entretanto, representam população especial no IAMCSST, com altas taxas de reestenose e desfechos clínicos desfavoráveis, devendo-se indicar o uso de stents farmacológicos (SF), nível de evidência A e classe de indicação II, para redução destes danos. Objetivo: Avaliar a taxa de uso de SF em pacientes com IAMCSST e no subgrupo dos diabéticos assistidos na rede pública versus privada de saúde em Sergipe. Métodos: Trata-se de um estudo populacional, transversal, com abordagem quantitativa, que utilizou os dados do Registro VICTIM. Estes foram coletados nos quatro únicos hospitais com capacidade para realizar AP em Sergipe, no período de dezembro de 2014 a março de 2017. Em todas as hipóteses testadas, o nível de significância adotado foi de 5% (p < 0,05). Resultados: Foram avaliados 707 pacientes diagnosticados com IAMCSST, dos quais 589 foram atendidos pelo SUS e 118 pela rede privada. O uso de SF na AP foi menor no SUS em comparação com a rede privada, tanto no total da amostra (10,5% vs 82,4%; p < 0,001) quanto no subgrupo dos pacientes diabéticos (8,7% vs 90,6%; p < 0,001), respectivamente. Conclusões: O estudo revela disparidade no uso de SF durante a realização de AP entre a rede pública e privada, tanto na amostra total quanto no subgrupo dos diabéticos, com menores taxas para usuários do SUS, demonstrando os desafios que necessitam ser vencidos para se atingir melhorias na qualidade dos serviços prestados.

Qualidade do Pré-Natal no Brasil: Pesquisa Nacional de Saúde 2013 / Quality of Prenatal Care in Brazil: National Health Research 2013

Resumo O objetivo deste estudo foi avaliar a adequação do cuidado pré-natal no Brasil associado a determinantes sociodemográficos. A pesquisa consistiu em uma análise dos dados da Pesquisa Nacional de Saúde realizada no Brasil em 2013. Foram avaliados dois desfechos sobre a adequação do pré-natal, o índice de Kessner modificado por Takeda que, além de levar em consideração esse índice, avaliou se houve aferição da pressão arterial e do peso em todas as consultas, realização de algum exame de sangue e urina e ultrassom. Ambos indicadores de qualidade foram avaliados para o Brasil e também pelas macrorregiões do país. De acordo com o desfecho 1, 80,6% das mulheres realizaram o pré-natal adequado. Ao adicionarmos a realização de exames (Desfecho 2) o percentual foi 71,4%. O pré-natal adequado foi mais frequente entre as mulheres de cor branca e que realizaram o pré-natal na rede privada. A região norte apresentou as menores frequências de pré-natal adequado, enquanto a região sudeste as maiores. Apesar da ampla cobertura, o pré-natal no Brasil ainda apresenta iniquidades e baixa qualidade no atendimento, especialmente entre mulheres das regiões mais pobre do país.

Abstract This study aimed to assess the adequacy of prenatal care in Brazil associated with sociodemographic determinants. The study included a data analysis from the National Health Research performed in Brazil in 2013. Two outcomes on the adequacy of prenatal care were assessed: the Kessner index modified by Takeda index that, in addition to the former, assessed whether blood pressure and weight were measured in all appointments, as well as the performance of blood and urine tests and ultrasound. Both quality indicators were assessed for Brazil and for its macro-regions. According to Outcome 1, 80.6% of women received adequate prenatal care. When adding the performance of tests (Outcome 2), the rate dropped to 71.4%. Adequate prenatal care was more frequent among white women who performed prenatal care in the private health sector. The northern region had the lowest rate of adequate prenatal care, while the southeast region showed the highest rates. Despite the extensive coverage, prenatal care in Brazil still presents inequities and low service quality, especially for women from the poorest regions of the country.

Factors associated with the number of filled teeth in adolescents from public schools: a cohort study

Abstract This study aimed to assess the association of demographic conditions, socioeconomic status, clinical variables, and psychosocial factors with the number of filled teeth in adolescents from public schools. This cohort study comprised 1,134 12-year-old adolescents enrolled in public schools in Santa Maria, Brazil, in 2012. They were followed-up in 2014, where 743 individuals were reassessed (follow-up rate of 65.52%) for the number of filled teeth. Data were collected via dental examinations and structured interviews. Demographic and socioeconomic characteristics were collected from parents or legal guardians. The psychosocial factor comprised students' subjective measurement of happiness (Brazilian version of the Subjective Happiness Scale - SHS). Dental examinations were performed to assess the number of filled teeth through decay, missing, and filled teeth index (DMF-T). Unadjusted and adjusted Poisson regression analyses were performed to assess the association between baseline variables and filled teeth at follow-up. The number of filled teeth in 2012 and 2014 were 193 (17.02%) and 235 (31.63%), respectively. The incidence of filled teeth in 2014 was 42 (5.65%). Adolescents with untreated dental caries, those who visited the dentist in the last 6 months, those that exhibited being happier, and those who had filled teeth at baseline were associated with a higher number of filled teeth at follow-up. We conclude that the number of filled teeth in adolescents was influenced by clinical and psychosocial factors, emphasizing the need to focus on oral health policies in individuals with higher disease burden and those who feel psychologically inferior.

Prevalence of overweight and obesity and associated factors in school children and adolescents in a medium-sized Brazilian city

OBJECTIVES: The objective of this study was to describe the prevalence of overweight and obesity in school children and adolescents in a medium-sized Brazilian city. METHODS: In total, 1,125 children and adolescents between the ages of 5.6 and 18 years from public and private schools participated in the study. The sample included 681 girls and 444 boys. Each subject's weight and height were obtained according to Brazilian guidelines (SISVAN). The triceps (TSF), subscapular (SSF), biceps, suprailiac, femoral and calf skinfolds were measured in triplicate. Body mass index (BMI) was classified as the BMI percentile (BMIP) according to the World Health Organization (WHO) 2007 criteria. The percentage body fat (%BF) was obtained using the equations by Slaughter et al., 1998. Categorical variables were analyzed using the chi-squared test. RESULTS: Overall, 364 participants with excess weight were identified: 17.3% were overweight, and 15.0% were obese. Among the girls, 18.0% were overweight, and 12.5% were obese; among the boys, 15.3% were overweight, and 18.0% were obese. These prevalence rates were higher when the time spent watching TV or participating in media-related activities surpassed 5 hrs/day, when individuals belonged to a higher economic class and when the head of the family had a higher education level (≥12 years). CONCLUSION: It is important to emphasize the need to increase our understanding of factors associated with overweight and obesity, and it is essential to implement measures and policies aimed at reversing this trend, such as stimulating healthy eating habits and physical activity and reducing time spent watching TV and participating in other media activities, including video games and social networking.

Factors associated with access to physical rehabilitation for victims of traffic accidents / Fatores associados ao acesso à reabilitação física para vítimas de acidentes de trânsito

ABSTRACT OBJECTIVE Evaluate the level of access to physical rehabilitation for survivors of traffic accidents and the associated factors. METHODS A cross-sectional study performed in Natal, Northeastern Brazil, through a telephone survey of 155 victims of traffic accidents admitted to an emergency hospital between January and August of 2013, with a diagnosis of fracture, traumatic brain injury or amputation. Participants were identified in the database of the reference hospital for care of traffic accident victims. We calculated point estimates and confidence interval (95%CI) for the frequency of subjects who had access, in addition to multivariate analysis (logistic regression) between access (dependent variable) and sociodemographic, clinical, and assistance variables. RESULTS Among the 155 respondents, the majority were adolescents and adults between 15–29 years of age (47.7%), men (82.6%), education up to high school (92.3%), income of up to two minimum wages (78.0%) and bikers (75.5%). Although 85.8% of traffic accident survivors reported the need for physical rehabilitation, there was little access (51.6%; 95%CI 43.7–59.4) and a delay to start the physical rehabilitation (average = 67 days). We classified factors associated with access to physical rehabilitation as: (i) unmodifiable individuals in the short term – family income greater than two minimum wages (OR = 3.7), informal worker (OR = 0.11) or unemployed (OR = 0.15) and possession of a private health care plan (OR = 0.07); and (ii) assistance modifiable by service management – written referral for physical rehabilitation (OR = 27.5) and perceived need of physical rehabilitation (OR = 10). CONCLUSIONS This study found a low and slow access to physical rehabilitation for individuals potentially in need. The associated factors were the organizational processes of health care (health information and referral) and social determinants (income, occupation and private health care plan).

RESUMO OBJETIVO Avaliar o nível de acesso à reabilitação física para sobreviventes de acidentes de trânsito e seus fatores associados. MÉTODOS Estudo transversal realizado em Natal, Nordeste do Brasil, com inquérito telefônico a 155 vítimas de acidentes de trânsito atendidos no hospital de emergência, entre janeiro e agosto de 2013, com diagnóstico de fratura, traumatismo cranioencefálico ou amputação. Os participantes foram identificados no banco de dados do hospital referência para atendimentos de acidentes de trânsito. Calculou-se a estimativa pontual e o intervalo de confiança (IC95%) da porcentagem de acesso e tempo para acesso, além de análise multivariada (regressão logística) entre o acesso (variável dependente) e as variáveis sociodemográficas, clínicas e assistenciais. RESULTADOS Entre os 155 entrevistados, predominaram jovens e adultos de 15–29 anos (47,7%), sexo masculino (82,6%), escolaridade até o ensino médio (92,3%), renda de até dois salários mínimos (78,0%) e motociclistas (75,5%). Embora 85,8% dos sobreviventes de acidentes de trânsito tivessem relatado a necessidade de reabilitação física, houve baixo acesso geral (51,6%; IC95% 43,7–59,4) e demora para início da reabilitação física (média = 67 dias). Os fatores associados ao acesso à reabilitação física classificaram-se em: (i) individuais não modificáveis em curto prazo – renda familiar maior que dois salários mínimos (OR = 3,7), ser trabalhador informal (OR = 0,11) ou desempregado (OR = 0,15) e ter plano privado de saúde (OR = 0,07); e (ii) assistenciais modificáveis pela gestão do serviço – encaminhamento escrito para reabilitação física (OR = 27,5) e necessidade percebida de reabilitação física (OR = 10). CONCLUSÕES Este estudo encontrou um baixo e demorado acesso à reabilitação física para indivíduos potencialmente necessitados. Os fatores associados foram os processos organizativos dos cuidados em saúde (encaminhamento e informação em saúde) e os determinantes sociais (renda, ocupação e plano privado de saúde).

Assistência pré-natal no Brasil / El cuidado prenatal en Brasil / Prenatal care in Brazil

O estudo tem por objetivo analisar a assistência pré-natal oferecida às gestantes usuárias de serviços de saúde públicos e/ou privados utilizando dados da pesquisa Nascer no Brasil, realizada em 2011 e 2012. As informações foram obtidas por meio de entrevista com a puérpera durante a internação hospitalar e dados do cartão de pré- natal. Os resultados mostram cobertura elevada da assistência pré-natal (98,7%) tendo 75,8% das mulheres iniciado o pré-natal antes da 16a semana gestacional e 73,1% compareceram a seis ou mais consultas. O pré-natal foi realizado, sobretudo, em unidades básicas (89,6%), públicas (74,6%), pelo mesmo profissional (88,4%), em sua maioria médicos (75,6%), e 96% receberam o cartão de pré-natal. Um quarto das gestantes foi considerado de risco. Do total das entrevistadas, apenas 58,7% foram orientadas sobre a maternidade de referência, e 16,2% procuraram mais de um serviço para a admissão para o parto. Desafios persistem para a melhoria da qualidade dessa assistência, com a realização de procedimentos efetivos para a redução de desfechos desfavoráveis.

El estudio tiene por objetivo describir el cuidado prenatal ofrecido a las embarazadas por parte de los servicios de salud públicos o privados en Brasil, utilizando los datos de la encuesta Nacer en Brasil, realizada en 2011 y 2012. La información se obtuvo mediante entrevistas con las mujeres después del parto, durante la hospitalización, y la ficha prenatal. Los resultados indican una alta cobertura (98,7%), con un 75,8% de las mujeres que comenzaron la atención prenatal antes de las 16 semanas de gestación y un 73,1% que tuvieron seis o más consultas. La atención prenatal se llevó a cabo en las unidades básicas de atención (89,6%), públicas (74,6%), por un mismo profesional (88,4%), la mayoría médicos (75,6%) y el 96% recibió una ficha prenatal. Una cuarta parte de las mujeres se consideraba en riesgo. Del total, sólo el 58,7% estaban orientadas sobre la unidad de maternidad de referencia, y el 16,2% dice que han buscado más de un servicio para el parto. Sigue habiendo problemas para mejorar la calidad de la atención, y es necesaria la realización de procedimientos efectivos para reducir los resultados desfavorables.

This study aims to describe prenatal care provided to pregnant users of the public or private health services in Brazil, using survey data from Birth in Brazil, research conducted from 2011 to 2012. Data was obtained through interviews with postpartum women during hospitalization and information from hand-held prenatal notes. The results show high coverage of prenatal care (98.7%), with 75.8% of women initiating prenatal care before 16 weeks of gestation and 73.1% having six or more number of appointments. Prenatal care was conducted mainly in primary health care units (89.6%), public (74.6%), by the same professional (88.4%), mostly physicians (75.6%), and 96% received their hand-held prenatal notes. A quarter of women were considered at risk of complications. Of the total respondents, only 58.7% were advised about which maternity care service to give birth, and 16.2% reported searching more than one health service for admission in labour and birth. Challenges remain for improving the quality of prenatal care, with the provision of effective procedures for reducing unfavourable outcomes.

Malignant melanoma in Chile: different site distribution between private and state patients

BACKGROUND: The body site location of primary Malignant Melanoma (MM) has been correlated with prognosis and survival. Ethnic, genetics, sun exposure factors are related to the anatomical distribution of MM. Low and high socioeconomic strata in Chile differ in ethnic, genetic and cultural conditions. The purpose of this study was to analyze the anatomical MM distribution in the Chilean population in both strata searching for differences due to their ethno-genetic-cultural differences. Records of 1148 MM, 575cases from state hospitals (Low Socioeconomic Strata, LSS) and 573 cases from private clinics (High Socioeconomic Strata, HSS) were analyzed by body site. RESULTS: Females from LSS showed a higher number of MM in soles, cheeks, and around the eye area. Females from the HSS showed a higher number of MM in dorsal feet and dorsal hands. Males from LSS showed a higher number of MM in soles, around the eye area, and cheeks. However, males from HSS showed a higher number of MM in the trunk, and in the arms. Acral MM was significantly higher in LSS than in the HSS in both sexes. The Chilean population from the HSS and LSS showed differences in the distribution of MM by site. Furthermore, gender differences in the proportion of MM analyzed by anatomical site are observed in both strata. CONCLUSIONS: Results show evidence that differential genetics factors, sun exposure, or other environmental or cultural factors of both strata may account for these differences.

Prevalencia de tracoma entre escolares brasileiros / Prevalencia de tracoma entre escolares brasilenos / Prevalence of trachoma in Brazilian schoolchildren

OBJETIVO: Estimar a prevalência e descrever a distribuição do tracoma entre escolares em municípios brasileiros. MÉTODOS: Estudo de corte transversal, usando amostragem por conglomerados, da população escolar dos municípios brasileiros com Índice de Desenvolvimento Humano-Municipal menor que a média nacional. O inquérito de prevalência de tracoma foi realizado pelo Ministério da Saúde entre 2002 e 2007. Foram selecionados 119.531 alunos de 2.270 escolas localizadas em 1.156 municípios. Os alunos foram submetidos ao exame ocular externo, com lupa (2,5X), para detecção de sinais clínicos de tracoma segundo critérios da OMS. Estimou-se a prevalência de tracoma segundo estado e em nível nacional, e seus respectivos intervalos de 95% de confiança. Para a comparação de variáveis categóricas foram usados os testes do Qui-quadrado e do Qui-quadrado de tendência linear. RESULTADOS: Foram detectados 6.030 casos de tracoma, resultando em prevalência de 5,0% (IC95% 4,5;5,4). Não foi encontrada diferença significante entre os sexos. A prevalência de tracoma foi de 8,2% entre menores de cinco anos de idade, diminuindo nas faixas etárias mais altas (p < 0,01). Houve diferença significante entre as prevalências de tracoma na zona urbana e rural, 4,3% versus 6,2%, respectivamente (p < 0,01). Foram detectados casos em 901 municípios (77,7% da amostra), em todas as regiões do País. Em 36,8% dos municípios selecionados a prevalência foi superior a 5%. CONCLUSÕES: O estudo mostra que o tracoma é um importante problema de saúde pública no Brasil, contradizendo a crença de que a endemia estaria controlada no País. O inquérito realizado apresenta uma linha de base para avaliação das intervenções ...

OBJETIVO: Estimar la prevalencia y describir la distribución de tracoma entre escolares en municipios brasileños MÉTODOS: Estudio de corte transversal, usando muestreo por conglomerados, de la población escolar de los municipios brasileños con Índice de Desarrollo Humano-Municipal menor que el promedio nacional. La pesquisa de prevalencia de tracoma fue realizada por el Ministerio de la Salud entre 2002 y 2007. Se seleccionaron 119.531 alumnos de 2.270 escuelas localizadas en 1.156 municipios. Los alumnos fueron sometidos a examen ocular externo, con lupa (2,5X), para detección de señales clínicas de tracoma según criterios de la OMS. Se estimó la prevalencia de tracoma según estado y a nivel nacional, y sus respectivos intervalos de 95% de confianza. Para la comparación de variables categóricas se usaron las pruebas de Chi-cuadrado y de Chi-cuadrado de tendencia linear. RESULTADOS: Se detectaron 6.030 casos de tracoma, resultando en prevalencia de 5,0% (IC95% 4,5;5,4). No se encontró diferencia significativa entre los sexos. La prevalencia de tracoma fue de 8,2% entre menores de cinco años de edad, disminuyendo en los grupos etarios más altos (p0,01). Hubo diferencia significativa entre las prevalencias de tracoma en la zona urbana y rural, 4,3% vs. 6,2%, respectivamente (p0,01). Se detectaron casos en 901 municipios (77,7% de la muestra), en todas las regiones del País. En 36,8% de los municipios seleccionados la prevalencia fue superior a 5%. CONCLUSIONES: El estudio muestra que el tracoma es un importante problema de salud pública en Brasil, contradiciendo la creencia de que la endemia estaría controlada en el País. La pesquisa realizada presenta una línea de base para evaluación de las intervenciones planeadas con miras a alcanzar la meta mundial de certificación de eliminación del tracoma como ...

OBJECTIVE: To estimate the prevalence and describe the distribution of trachoma among schoolchildren in Brazilian municipalities. METHODS: Cross-sectional study, using cluster sampling, of the schoolchildren population of the Brazilian municipalities with Human Development Index - Municipal lower than the national average. This trachoma prevalence survey was conducted by the Ministry of Health, in the period 2002-2007. There were 119,531 schoolchildren selected from 2,270 schools located in 1,156 municipalities. The selected schoolchildren underwent an external ocular examination, with a magnifying glass (2.5X), to detect clinical signs of trachoma according to the WHO criteria. The prevalence of trachoma, by state and national level, and their respective 95% confidence intervals were estimated. Chi-square and Chi-square for trends tests were used to compare categorical variables. RESULTS: There were 6,030 cases of trachoma detected, resulting in a prevalence of 5.0% (95%CI 4.5;5.4). There was no significant difference between the sexes. The prevalence of trachoma was 8.2% among children under 5 years of age, decreasing among higher age groups (p < 0.01). There was a significant difference in prevalence between urban and rural areas, 4.3% versus 6.2% respectively (p < 0.01). Cases were detected in 901 municipalities (77.7% of the sample), in all regions of the country. In 36.8% of the selected municipalities, the prevalence was higher than 5%. CONCLUSIONS: The study shows that trachoma is a significant public health problem in Brazil, contradicting the belief that the disease had been controlled in the country. The survey provides a baseline for evaluating planned interventions aimed at achieving the goal of global certification of elimination of trachoma as a cause of blindness in Brazil by 2020. .

Excesso de peso em crianças de pré-escolas: prevalência e fatores associados / Excess weight in preschoolers: prevalence and associated factors

OBJETIVO: Estudar a prevalência e os fatores associados ao excesso de peso em crianças matriculadas em escolas públicas dos estados do Rio Grande do Sul (RS) e Santa Catarina (SC). MÉTODOS: Realizou-se estudo transversal com crianças de idade entre quatro e seis anos. O desfecho estudado foi o excesso de peso, definido através do escore Z > 2DP para o Índice de Massa Corporal (IMC)/idade, em comparação com a população de referência da OMS 2006/2007. As medidas antropométricas de massa corporal e altura foram aferidas em duplicata, utilizando-se técnicas padronizadas conforme a Organização Mundial de Saúde (OMS). Os dados foram duplamente digitados utilizando o software EPI-INFO, versão 6.04. Foram calculadas frequências absolutas e relativas e médias (DP). Associações entre excesso de peso e demais variáveis foram avaliadas em modelo de Poisson de variância robusta. Foi utilizado o programa STATA versão 12.0 (p < 0,05). RESULTADOS: Foram avaliadas 4.914 crianças (RS 2.578 e SC 2.336). No RS, o excesso de peso foi de 14,4% (IC 95% = 13,1-15,8%) e, em SC, de 7,5% (IC 95% = 6,5-8,7%). As variáveis que apresentaram associação com o excesso de peso foram: número de moradores no domicílio; escolaridade materna; situação conjugal; número de filhos; idade materna ao nascimento do primeiro filho; idade gestacional; e o peso ao nascer. CONCLUSÃO: As crianças matriculadas nas pré-escolas públicas do RS apresentaram uma prevalência de excesso de peso duas vezes maior do que a identificada em SC, demonstrando uma diferença significativa na magnitude da obesidade infantil em dois estados brasileiros situados em uma mesma região.

OBJECTIVE: To study the prevalence and factors associated with excess weight in children enrolled in public schools in the states of Rio Grande do Sul (RS) and Santa Catarina (SC). METHODS: This was a cross-sectional study, carried out with children aged 4 to 6 years. The studied outcome was excess weight, defined by z-score > two standard deviations for body mass index (BMI)/age, compared with the World Health Organization (WHO) reference population of 2006/2007. Anthropometric measurements of body mass and height were measured in duplicate using standard techniques, in accordance with the WHO. Data were double entered using EPI-INFO software, release 6.04. Absolute and relative frequencies were calculated, as well as mean values and standard deviations. Associations between excess weight and other variables were assessed by using Poisson model with robust variance. STATA software release 12.0 was used (p < 0.05). RESULTS: A total of 4,914 children were evaluated (2,578 in RS and 2,336 in SC). In RS, the incidence of excess weight was 14.4% (95% CI = 13.1% to 15.8%) and in SC, 7.5% (95% CI = 6.5% to 8.7%). The variables associated with excess weight were number of household members, maternal education, marital status, number of children, mother's age at birth of first child, gestational age, and birth weight. CONCLUSIONS: Children enrolled in public preschools in RS had a two-fold higher excess weight prevalence than that identified in SC, demonstrating a significant difference in the magnitude of childhood obesity in two Brazilian states located in the same region.

Assistência pré-natal nos serviços públicos e privados de saúde: estudo transversal de base populacional em Rio Grande, Rio Grande do Sul, Brasil / Prenatal care in public and private health services: a population-based survey in Rio Grande, Rio Grande do Sul State, Brazil

Este estudo teve por objetivo avaliar a assistência recebida durante o pré-natal nos setores público e privado em Rio Grande, Rio Grande do Sul, Brasil. Aplicou-se questionário padronizado a todas as mães residentes nesse município, cujos filhos nasceram nas duas únicas maternidades locais entre 1º de janeiro e 31 de dezembro de 2010. Os locais de consultas avaliados no setor público foram as unidades básicas de saúde (UBS) com e sem Estratégia Saúde da Família (ESF) e os ambulatórios; no setor privado foram as clínicas de convênio e os consultórios particulares. Utilizou-se o teste qui-quadrado para comparar proporções. A taxa de respondentes foi de 97,2% (2.395 em 2.464). Dentre as 23 variáveis e indicadores avaliados nesses locais, sete mostraram nítida vantagem para mães que consultaram na ESF e seis para mães atendidas em clínica de convênio e consultório particular. Quatro variáveis mostraram cobertura praticamente universal nos cinco locais estudados. A assistência pré-natal mostrou melhor cobertura para gestantes atendidas no setor privado. Gestantes atendidas na ESF apresentaram cobertura semelhante àquela observada no setor privado.

This study aimed to evaluate public and private prenatal care for women in Rio Grande, Rio Grande do Sul State, Brazil. Women who gave birth at the two local maternity hospitals from January 1 to December 31, 2010, answered a standardized questionnaire. The interview sites in the public sector were primary health care units with and without the Family Health Strategy (FHS) and outpatient clinics; the private sector included clinics operated by health plans and private physicians' offices. The chi-square test was used to compare proportions. The response rate was 97.2% (2,395 out of 2,464). Among the 23 target variables and indicators, seven showed a clear advantage for mothers who had received prenatal care under the FHS and six for health plan clinics and private offices. Four variables showed virtually universal coverage at all five study sites. Prenatal care showed better coverage for pregnant women treated in the private sector. Pregnant women treated under the FHS showed similar coverage to that in the private sector.

Comparison of the epidemiologic features and patterns of initial care for prostate cancer between public and private institutions: a survey by the Brazilian Society of Urology

OBJECTIVE: To describe the epidemiological features and patterns of initial care for prostate cancer at public and private institutions in the State of Sao Paulo, Brazil. MATERIALS AND METHODS: A total of 1,082 physicians affiliated to the Sao Paulo Section of the Brazilian Society of Urology were invited to participate in this cross-sectional, web-based survey. Between September 2004 and September 2005, participating urologists entered data on demographic, clinical and pathological characteristics of patients diagnosed with prostate cancer in their practice. Data on patients attended at public institutions were analyzed and compared with those patients attended at private practice. RESULTS: One hundred and ten society members contributed with data from 1915 patients, 1026 (53.6%) of whom from public institutions. When compared with patients attended at private institutions, those attended at public institutions were older and more likely to be black, had higher serum prostate specific antigen (PSA) levels, had a higher probability of being diagnosed with metastatic disease, but were less likely to undergo prostatectomy (all P < 0.001). In multivariate analysis, age, biopsy Gleason score, and being attended at a public institution were independently associated with metastatic disease upon diagnosis. The significant predictors of nonsurgical treatment were age, black race, and higher serum levels of PSA. CONCLUSIONS: A statewide registry provides valuable information regarding patient demographics, clinical features, and patterns of care. The results of this study suggest that significant disparities exist for patients with prostate cancer attended at different health-care systems. The relative contribution of biological versus socioeconomic features remains uncertain.

Formación de médicos especialistas en el Sistema de Servicios de Salud de Chile: Su evolución en el período 2007-2010 / Training of specialists in the Chilean national health services

Several institutions, such as the Ministry of Health, Universities, the Chilean Medical Association, Scientific societies and public opinion, recognize that there is a deficiency of specialized physicians in Chile. To overcome this shortage of specialists, the Ministry of Health, along with universities, is developing diverse initiatives to train specialists and cope with the requirements of the country. Seventy five percent of posts offered were filled by physicians. The number of positions increased from 173 in 2007 to 576 in 2010, with a cumulative total of 1582 physicians in four years. Fifty two percent are being trained in Basic Primary Specialties and 48 percent in primary specialties. Thirty three percent of graduates have the obligation to continue working in the public service during a certain lapse. This figure will increase to 50 percent in the following years. These specialists are mainly working in the more densely populated regions of the country. The universities that offer the higher number of training positions are the University of Chile, The Catholic University of Chile and the University of Santiago.

Letalidad del cáncer de vesícula biliar es independiente del lugar de atención o características sociodemográficas: Chile 2002-2005 / Mortality due to gallbladder cancer: Retrospective analysis in three Chilean hospitals

Background: Chile has the highest gallbladder cancer (GBC) death rate world-wide, affecting mainly Southern areas of the country. Aim: To compare the survival of GBC patients treated in hospitals located in areas with low and high risk for GBC. Material and Methods: Medical records of all patients with GBC admitted to one public hospital located in southern Chile, a public hospital and a private clinic, both located in Metropolitan Santiago, were reviewed. Cases were analyzed by age, sex, stage at diagnosis, ethnicity, socioeconomic status (SES) and rural residence. Survival was calculated using Kaplan Meier method. Results: A total of 598 cases (469 women), were analyzed. No differences in age or sex among hospitals were detected. At the moment of diagnosis, 75, 50 and 44 percent of cases from the hospital in southern Chile, the public hospital in Santiago and the private clinic in Santiago, were in stage IV, respectively. Five years survival was lower in the public hospital in southern Chile than in the public hospital in Santiago (10.7 and 14.4 percent respectively, p < 0.05) but not statistically different from the figure at the private clinic in Santiago (13.0 percent). However, when adjusting for stage at the moment of diagnosis, no difference in survival between the three hospitals, was found. The median days of survival were 1,559, 188, 70 and 69 for stages I, II, III and IV respectively. Conclusions: GBC mortality is high. The stage at the moment of diagnosis is only significant predictor of survival.

Custo-efetividade de cardiodesfibriladores implantáveis no Brasil nos setores público e privado / Cost-effectiveness of implantable cardioverter defibrillators in Brazil in the public and private sectors

FUNDAMENTO: Vários ensaios clínicos randomizados demonstraram a efetividade do cardiodesfibrilador implantável (CDI) na redução de morte de pacientes com insuficiência cardíaca congestiva (ICC). Estudos de países desenvolvidos já avaliaram a custo-efetividade do CDI, porém as informações não são transferíveis para o Brasil. OBJETIVO: Avaliar a custo-efetividade do CDI em pacientes com ICC sob duas perspectivas: pública e saúde suplementar. MÉTODOS: Um modelo de Markov foi criado para analisar a relação de custo-efetividade incremental (RCEI) do CDI, comparado à terapia convencional, em pacientes com ICC. Efetividade foi medida em anos de vida ajustados para qualidade (QALY). Na literatura, buscaram-se dados de efetividade e complicações. Custos foram extraídos das tabelas do SUS e de valores praticados pelos convênios, assim como médias de internações hospitalares. Análises de sensibilidade univariadas foram feitas em todas as variáveis do modelo. RESULTADOS: A RCEI foi de R$ 68.318/QALY no cenário público e R$ 90.942/QALY no privado. Esses valores são superiores aos sugeridos como pontos de corte pela Organização Mundial da Saúde, de três vezes o PIB per capita (R$ 40.545 no Brasil). Variáveis mais influentes na análise de sensibilidade foram: custo do CDI, intervalo de troca do gerador e efetividade do CDI. Em simulação de cenário semelhante ao MADIT-I, as relações foram de R$ 23.739/QALY no cenário público e R$ 33.592/QALY no privado. CONCLUSÃO: Para a população em geral com ICC, a relação de RCEI do CDI, tanto na perspectiva pública como na privada, é elevada. Resultados mais favoráveis ocorrem em pacientes com alto risco de morte súbita.

BACKGROUND: Many randomized clinical trials have demonstrated the effectiveness of the implantable cardioverter-defibrillator (ICDs) in death reduction of chronic heart failure (CHF) patients. Some developed countries studies have evaluated its cost-effectiveness, but these data are not applicable to Brazil. OBJECTIVE: To evaluate the cost-effectiveness of ICD in CHF patients under two perspectives in Brazil: public and supplementary health systems. METHODS: A Markov model was developed to analyze the incremental cost-effectiveness ratio (ICER) of ICD compared to conventional therapy in patients with CHF. Effectiveness was measured in quality-adjusted life years (QALYs). We searched the literature for data regarding effectiveness and complications. Costs were retrieved from public and health insurances reimbursement codebooks and from mean cost of admissions from a public and a private hospital. One-way sensitivity analysis was performed in all variables of the model. RESULTS: ICER was R$ 68,318/QALY in the public and R$ 90,942/QALY in the private perspective. These values are much higher than the one suggested by the World Health Organization of 3 times the gross domestic product per head (R$ 40,545 in Brazil). The results were sensitive to the cost of the device, battery replacement interval and ICD effectiveness. In a simulation resembling MADIT-I population survival and ICD benefit, ICER was R$ R$ 23,739/QALY in the public and R$ 33,592/QALY in the private perspective. CONCLUSION: The ICER aof ICD is elevated in the general ICC population, in either the public or private perspective. A more favorable result occurs in patients with a high sudden death risk.