Brazilian Healthcare System Research Articles

Factors associated with hospitalization and death among TB/HIV co-infected persons in Porto Alegre, Brazil.

In locations with a high rate of tuberculosis (TB) and HIV infection, there are a number of strategies to prevent negative outcomes such as opportunistic infections, hospitalizations and death, and this article investigates risk factors for the occurrence of hospitalization and death in cases of TB/HIV co-infection in the south of Brazil. The data are taken from a population-based retrospective cohort study on cases of TB/HIV co-infection from 2009 to 2013 in Porto Alegre, Brazil. Sociodemographic, epidemiological and clinical variables were analyzed. Relative risk (RR) estimates for hospitalization and death were determined by regression models. There were 2,419 co-infection cases, of which 1,527 (63.1%) corresponded to hospitalizations, and 662 (27.4%) to death. The occurrence of hospitalization was associated with ≤ 7 years of schooling (RR = 3.47, 95%CI: 1.97–6.29), 8–11 years of schooling (RR = 2.56, 95%CI: 1.44–4.69), place of origin—district health authorities Northwest/Humaitá/Navegantes/Ilhas (RR = 2.01, 95%CI: 1.44–2.82), type of entry into the surveillance system as in cases of reentry after withdrawal (RR = 1,35, 95%CI: 1.07–1.70), closure in surveillance as in withdrawal of treatment (RR = 1.47, 95%CI: 1.18–1.83) and multidrug-resistant tuberculosis (RR = 3.94, 95%CI: 1.97–8.81). The occurrence of death was associated with age (RR = 1.07, 95%CI: 1,01–1,14), ≤ 7 years of schooling (RR = 3.94, 95%CI: 2.26–7.09), 8–11 years of schooling (RR = 2.84, 95%CI: 1.61–5.16), place of origin—district health authorities Baltazar (RR = 2.05, 95%CI: 1.48–2.86), type of entry in the surveillance system as cases of re-entry after withdrawal (RR = 1.53, 95%CI: 1.22–1.91), relapse (RR = 1.33, 95%CI: 1.03–1.73). The occurrence of hospitalizations and deaths is high among co-infected patients. Our estimation approach is important in order to identify, from the surveillance data, the risk factors for hospitalization and death in co-infected patients, so that they may receive more attention from the Brazilian national healthcare system.

Nuclear Imaging Exams Authorized by the Brazilian Health Care System and Nuclear Imaging Equipment Distribution in the State of Rio Grande do Sul

Introduction: For nuclear imaging exams to be funded by the Brazilian public health care system (Sistema Único de Saúde, SUS), the institution must be first authorized by the National Nuclear Energy Commission (Comissão Nacional de Energia Nuclear, CNEN) to secure the safe use of radiation. Objective: To describe the distribution of equipment used in nuclear imaging exams and the quantity of exams funded by the SUS according to the macroregions defined by Rio Grande do Sul Health Department from 2013 to 2015. To check the consistency of data from the Department of Informatics of the Ministry of Health (Departamento de Informática do Sistema Único de Saúde, DATASUS) and the CNEN in November 2015. Methods: Secondary data from DATASUS and the CNEN were used. The region of health, the macroregion, and its respective estimated population were obtained from the Brazilian Institute of Geography and Statistics. Results: The Porto Alegre metropolitan area showed the largest concentration of gamma cameras. The number of exams was higher in philanthropic institutions with a valid register at the Brazilian Ministry of Health and federal funded organizations. Some regions had less CNEN-authorized institutions than SUS-authorized ones. Conclusion: The distribution of equipment and exams was uneven in the state.

Cost per number needed to treat and treatment cost of baricitinib versus adalimumab on rheumatoid arthritis treatment in the brazilian private healthcare system

Introduction: Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease. It is characterized by a persistent synovitis, progressively causing cartilage destruction and bone erosion, leading to joint deformation and disability. RA patients may have highly variable patterns of radiologic progression over time. In any case, joint damage and functional status loss appear since the early disease stages. RA can potentially involve other organs, causing, for instance, severe respiratory and/or cardiovascular complications; for this reason, a higher mortality risk (as compared with general population) is associated with RA. Biological disease-modifying antirheumatic drugs are recommended for use particularly in rheumatoid arthritis patients who had an inadequate response to methotrexate. Objectives: Using data on efficacy from the RA-BEAM trial (American College of Rheumatology (ACR) indices) and number needed to treat (NNT) (Rovasio et al 2018), the present economic analysis compared the cost per NNT (ACR 20, 50 and 70) on week 24 of Baricitinib (BARI) (4mg) and Adalimumab (ADA) (40mg) in adult patients with moderately to severely active RA with an inadequate response to methotrexate (MTX) in Brazil (R$, local currency). In addition to that, the direct treatment cost on weeks 12, 24 and 52 was also compared. Methods: The economic analysis for both biologic DMARDs (BARI 4mg and ADA 40mg) was developed considering the number of doses on each label with 12, 24 and 52 weeks of treatment; NNT on week 24 according to Rovasio et al 2018; drug acquisition cost using as reference the Brasíndice pharmaceutical guide (wholesale price + 18% taxes); the cost of MTX was not considered. Results: BARI presented lower treatment cost compared to ADA on weeks 12, 24 and 52, demonstrating 48% of reduction. BARI also presented lower NNT compared to ADA on week 24. The cost per responder considering ACR (20, 50 and 70) for BARI was lower compared to ADA (ACR20: R$66.915 vs R$162.096; ACR50: R$79.850 vs R$183.741; ACR70: R$114.178 vs R$348.723, respectively). Conclusion: The results from this economic evaluation, based on the cost per NNT (Rovasio et al 2018) in combination with drug acquisition cost (Brasíndice pharmaceutical guide), showed that BARI is a more cost-effective therapeutic option when compared with ADA in the treatment of moderately to severely active RA in adult patients with an inadequate response to MTX.

Who and Where are the University of São Paulo Medical School Graduates?

OBJECTIVE:To evaluate the impact of a complex-care-based medical school in the context of the Brazilian health care system on students' career choices.METHODS:This was a retrospective cross-sectional study based on medical regulatory organization records. It included records for 7,419 physicians who graduated from FMUSP. Geographic data were analyzed using Kernel maps, and the statistical analysis was performed with SPSS® version 24.0. A p-value less than 0.05 was considered significant.RESULTS:Of the 7,419 physicians, 68.6% (95% CI 67.5-69.7) were male, and 20.7% (95% CI 19.8%-21.7%) had no medical specialty, compared to 46.4% nationwide. Internal medicine and surgery-based specialties were more popular, accounting for 39.4% (95% CI 38.3%-40.5%) and 16.8% (95% CI 15.5%-17.6%) of our study group, compared to the Brazilian averages of 25.9% and 13.5%. Our graduates also had a higher probability of staying in São Paulo City, especially when born outside the city.CONCLUSION:We believe that FMUSP remains an interesting model for studying the impact of a highly specialized center on the education and career choices of medical students.

A atuação do residente em Odontologia Hospitalar neonatal na abordagem multidisciplinar do SUS: relato de experiência

A reorganização dos serviços de saúde vinculada ao programa Humaniza SUS possibilita o cuidado multiprofissional do indivíduo. Neste sentido, a inclusão do cirurgião-dentista nas equipes visa somar esforços para o alcance da integralidade da atenção, a qual abrange as diversas alterações que podem acometer o sistema estomatognático de sujeitos em cuidados hospitalares. A residência em odontologia hospitalar neonatal, como parte integradora da abordagem multiprofissional, é extremamente importante para garantir a abordagem adequada de gestantes, puérperas e recém-nascidos (RN) em sua plenitude. As frentes de atuação do residente em odontologia neonatal envolvem, principalmente, o pré-natal odontológico, o puerpério imediato e mediato, a abordagem ambulatorial e as unidades de terapia intensiva neonatal e pediátrica. Este artigo objetiva relatar a experiência de atuação de residentes em odontologia hospitalar neonatal em um hospital escola pertencente ao Sistema Único de Saúde (SUS) do Paraná.

HEPATITIS C IN THE BRAZILIAN PUBLIC HEALTH CARE SYSTEM: BURDEN OF DISEASE

Infection by hepatitis C virus is one of the leading causes of chronic hepatitis C and cause severe burden for patients, families and the health care system. The aims of this research were to assess the severity of liver fibrosis, comorbidities and complications of hepatitis C virus; to examine health-related quality of life (HRQoL), productivity loss and resource use and costs in a sample of Brazilian chronic hepatitis C, genotype 1, patients. This was a cross-sectional multicenter study performed in genotype-1 chronic hepatitis C patients to assess disease burden in the Brazilian public health care system between November 2014 and March 2015. Patients were submitted to a liver transient elastography (FibroScan) to assess liver fibrosis and answered an interview composed by a questionnaire specifically developed for the study and three standardized questionnaires: EQ-5D-3L, HCV-PRO and WPAI:HepC. There were 313 subjects enrolled, with predominance of women (50.8%), caucasian/white (55.9%) and employed individuals (39.9%). Mean age was 56 (SD=10.4) years old. Moreover, 42.8% of patients who underwent FibroScan were cirrhotic; the most frequent comorbidity was cardiovascular disease (62.6%) and the most frequent complication was esophageal varices (54.5%). The results also showed that "pain and discomfort" was the most affected HRQoL dimension (55.0% of patients reported some problems) and that the mean HCV-PRO overall score was 69.1 (SD=24.2). Regarding productivity loss, the most affected WPAI:HepC component was daily activity (23.5%) and among employed patients, presenteeism was more frequent than absenteeism (18.5% vs 6.5%). The direct medical costs in this chronic hepatitis C sample was 12,305.72USD per patient in the 2 years study period; drug treatment costs represented 95.9% of this total. This study showed that most patients are cirrhotic, present high prevalence of cardiometabolic diseases and esophageal varices, reduced HRQoL mainly in terms of pain/discomfort, and work productivity impairment, especially presenteeism. Additionally, we demonstrated that hepatitis C virus imposes an economic burden on Brazilian Health Care System and that most of this cost is due to drug treatment.

Cost effectiveness analysis of plasma genotyping versus tumor genotyping in detection of advanced non-small-cell lung cancer with epidermal growth factor receptor and T790M mutation under the Brazilian private healthcare system perspective

Objective: Comparing the costs and effectiveness of plasma genotyping versus tumor genotyping for detecting the T790M mutation in advanced non-small cell lung cancer (NSCLC) with a mutation in the epidermal growth factor receptor (EGFR) and that progressed after use of an EGFR tyrosine kinase inhibitor (EGFR-TKI), from the perspective of the private healthcare system in Brazil. Methods: Patients with a post-EGFR-TKI T790M mutation are eligible for a second-line treatment with a third- -generation EGFR-TKI (osimertinib). In order to estimate the costs associated with the diagnosis method for the T790M mutation, a decision tree model has been used. Resource use was estimated by a team of experts, and the direct costs were estimated based on official databases. Results: Plasma genotyping provided a R$391 reduction per patient, due to the reduced cost with complications; it prevented 40.96% of the patients from undergoing an invasive procedure and 31.91% of the pa[1]tients from having any kind of complication. Conclusion: Data found support a new paradigm for treating the resistance to EGFR-TKIs, with plasma genotyping as the first diagnostic choice, what can help to define the treatment and to reduce the costs of Brazilian private healthcare system.

PO403 Integration of Telemedicine and Echocardiography By Non-Physicians Into the Primary Healthcare System In Brazil

The clinical importance of random urine creatinine concentration in CKD population remains undetermined. Earlier studies found that lower 24-h urine creatinine excretion was associated with the risk of ESRD and all-cause mortality among CKD patients.We modeled the longitudinal trajectories of serial random urine creatinine among 4689 CKD patients enrolled in a national registry-based pre-ESRD program between 2003 and 2015 at a tertiary medical center. Other biochemical parameters including kidney function and serum albumin were regularly evaluated. Primary study outcomes were ESRD requiring maintenance dialysis and all-cause mortality.By group-based trajectory modeling, the urine creatinine trajectories were characterized into three patterns: (1) stable low; (2) medium; and (3) high-declining. The adjusted hazard ratio of incident ESRD and all-cause mortality increased by 6% (95% CI: 1–12%) and 9% (95% CI: 2–17%), respectively, for each 20 mg/dL reduction in baseline random urine creatinine concentration. Consistently, there was a significant inverse linear dose-response relationship between baseline random urine creatinine and incident ESRD, but not all-cause mortality. Compared to patients with “medium” and “high-declining” urine creatinine trajectories combined, the adjusted hazard ratio for incidental ESRD among patients with a “stable-low” trajectory who had serial random urine creatinine concentrations stably below 100 mg/dL was 1.46 (95% CI: 1.00–2.12) after considering the competing risk of death.Random urine creatinine not only serves as a common urinary concentration corrector but has its own clinical significance in risk stratification and outcome prediction in patients with advanced CKD.

Translating and Adapting the Patient Perception of Integrated Care Survey to Evaluate Integrated Care in Brazil: Preliminary Results

Introduction: the increase in initiatives to improve integration of care for patients with chronic illness has risen on all over the world. This context claims the need for instruments able to evaluate the integrated care as perceived by patients across different cultural context. This abstract aims to describe the preliminary results forward translation and the expert panel of translation and cultural adaptation of the Patient Perception of Integrated Care PPIC survey to measure integrated care in Brazil. Methods: the PPIC survey version 2.1 served as basis for this methodological study after authorization granted by the original authors. For the process of translation and adaptation, we used the World Health Organization WHO guideline, including, sequentially, forward translation, expert panel, back-translation and pre-testing with cognitive interviewing. After expert panel, Content Validity Index CVI was calculated for each item for measuring the proportion of members in agreement with the translation proposed in first step. Beyond to analyzing each item individually, the instrument was evaluated as a whole. CVI ≥ 0.80 was adopted as indicator of adequacy of the translation to the original text. Results: the forward translation and the expert panel produced a Portuguese initial version of the PPIC survey with important adaptations. These adaptations resulted from differences relate to the context of Brazilian healthcare system Sistema Unico de Saude and are cultural/structural nature. The bilingual English and Portuguese expert panel, was composed by 5 members including experts in health, experts in linguistic as well as experts with experiences in instrument development and translation. The panel assess 76 items, being 64 questions e others 12 items related instructions and session titles. The mean CVI was 0.98 and all the suggestions made by the panel' members were discussed until to obtain the consensual version. Discussion: the WHO guideline is being very useful in guiding this process. Our partial results show that forward translation and expert panel are fundamental steps of translation and adaptation of instruments that need to be conducted carefully. This two steps showed that choosing words or expressions is a delicate procedure and need a rigorous examination. To ensure that questions content was not affected by adaptations, in the next steps, we will check for conceptual equivalence with the backward translation. Conclusions: the results of the two initial steps of the process of translation and adaptation of PPIC survey are promising for its adoption in Brazilian context for evaluate integrated care. Lessons learned: the results reached till the moment has shown that to focus on cross-cultural and conceptual, rather than on linguistic or literal equivalence, is the key point of these initial steps to achieve different language versions of the original instrument. Limitations: the forward translation and the expert panel were very important to produce a comprehensive starting version equivalent to the original instrument. However, it needs additional steps to successfully transfer the PPIC survey to Brazilian context. Suggestions for future research: after the final version, it will be necessary to determine the validity of the Brazilian PPIC survey through psychometric testing.

Patient-centered primary care and self-rated health in 6 Latin American and Caribbean countries: Analysis of a public opinion cross-sectional survey.

BackgroundDespite the substantial attention to primary care (PC), few studies have addressed the relationship between patients’ experience with PC and their health status in low-and middle-income countries. This study aimed to (1) test the association between overall patient-centered PC experience (OPCE) and self-rated health (SRH) and (2) identify specific features of patient-centered PC associated with better SRH (i.e., excellent or very good SRH) in 6 Latin American and Caribbean countries.Methods and findingsWe conducted a secondary analysis of a 2013 public opinion cross-sectional survey on perceptions and experiences with healthcare systems in Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama; the data were nationally representative for urban populations. We analyzed 9 features of patient-centered PC. We calculated OPCE score as the arithmetic mean of the PC features. OPCE score ranged from 0 to 1, where 0 meant that the participant did not have any of the 9 patient-centered PC experiences, while 1 meant that he/she reported having all these experiences. After testing for interaction on the additive scale, we analyzed countries pooled for aim 1, with an interaction term for Mexico, and each country separately for aim 2. We used multiple Poisson regression models double-weighted by survey and inverse probability weights to deal with the survey design and missing data. The study included 6,100 participants. The percentage of participants with excellent or very good SRH ranged from 29.5% in Mexico to 52.4% in Jamaica. OPCE was associated with reporting excellent or very good SRH in all countries: adjusting for socio-demographic and health covariates, patients with an OPCE score of 1 in Brazil, Colombia, El Salvador, Jamaica, and Panama were more likely to report excellent or very good SRH than those with a score of 0 (adjusted prevalence ratio [aPR] 1.61, 95% CI 1.37–1.90, p < 0.001); in Mexico, this association was even stronger (aPR 4.27, 95% CI 2.34–7.81, p < 0.001). The specific features of patient-centered PC associated with better SRH differed by country. The perception that PC providers solve most health problems was associated with excellent or very good SRH in Colombia (aPR 1.38, 95% CI 1.01–1.91, p = 0.046) and Jamaica (aPR 1.21, 95% CI 1.02–1.43, p = 0.030). Having a provider who knows relevant medical history was positively associated with better SRH in Mexico (aPR 1.47, 95% CI 1.03–2.12, p = 0.036) but was negatively associated with better SRH in Brazil (aPR 0.71, 95% CI 0.56–0.89, p = 0.003). Finally, easy contact with PC facility (Mexico: aPR 1.35, 95% CI 1.04–1.74, p = 0.023), coordination of care (Mexico: aPR 1.53, 95% CI 1.19–1.98, p = 0.001), and opportunity to ask questions (Brazil: aPR 1.42, 95% CI 1.11–1.83, p = 0.006) were each associated with better SRH. The main study limitation consists in the analysis being of cross-sectional data, which does not allow making causal inferences or identifying the direction of the association between the variables.ConclusionsOverall, a higher OPCE score was associated with better SRH in these 6 Latin American and Caribbean countries; associations between specific characteristics of patient-centered PC and SRH differed by country. The findings underscore the importance of high-quality, patient-centered PC as a path to improved population health.

Inclusion of Metastatic Breast Cancer Treatments in the SUS (Public Health Care System): Strategic Actions

Background and context: Thousands of women suffering from HER2+ metastatic breast cancer (MBC) in Brazil had limited access to treatment in the public health system (SUS). There were no innovative therapies (only standard chemotherapy) available for them. Trastuzumab is included in WHO´s essential medicines list and it began to be commercialized in Brazil in 1998, being available in SUS in 2012, but only for patients with local breast cancer. Pertuzumab was never available in SUS for any stage of the disease. Aim: Contribute to the inclusion of trastuzumab and pertuzumab in MBC treatments in the SUS. Strategy/Tactics: Federação Brasileira de Instituições Filantrópicas de Apoio à Saúde da Mama’s (FEMAMA´s) main strategy was to develop several projects with the same purpose. Program/Policy process: The cycles of debates with parliamentarians and public hearings (events) to discuss with politicians the incorporation of new treatments in 15 state legislative branches and also in the National Congress; Organization of 8 public hearings after the first event (mentioned above) and elaboration of a one-year plan of actions to be carried out alongside NGOs associated with FEMAMA for carrying out local actions; The Women´s Cancer Fight Forum (event) to strength and empower the role of NGOs in public health policies; The National Conference of Female Mayors and Governors and the National Conference of First Ladies (event), where women´s leaders from all regions and local NGOs worked together discussing problems and suggesting actions to combat them; The Ambassadors Project - Women in Defense of Breast Health, empowering patients to be spokespeople for the cause in their regions; Carry out surveys that show the difference in MBC treatments available for patients with health insurance and patients treated in the SUS; Participation in several events on this topic organized at the House of Representatives and at the Senate; Add this topic to the agenda of the National Health Council and of the 2015 National Health Conference; Awareness and mobilization campaigns for expanding access to treatment and empowerment of patients: Para Todas as Marias, Por Mais Tempo, Acesso Já, #PacientesNoControle - Atitude Exige Coragem; National campaign to promote the public consultation of the Ministry of Health on the incorporation of trastuzumab and pertuzumab treatments in SUS, #PatientsInControl. Outcomes: Several outcomes were obtained as a result of these projects and campaigns. However, our main result undoubtedly is assuring access to metastatic breast cancer treatments in the Brazilian health care system. On August 2017, the Ministry of Health announced the incorporation of trastuzumab for metastatic breast cancer in the public health system and on December 2017, it announced the incorporation of pertuzumab for the same patients. What was learned: Patients and articulated NGOs have power to change scenarios. Empowering patients by providing them with information and tools is an important way to promote changes.

PCV86 - COST-EFFECTIVENESS OF SACUBITRIL/VALSARTAN IN THE TREATMENT OF HEART FAILURE UNDER THE BRAZILIAN PRIVATE HEALTHCARE SYSTEM PERSPECTIVE

To estimate the cost-effectiveness of sacubitril/valsartan versus enalapril in the treatment of heart failure with reduced ejection fraction (HFrEF) New York Heart Association (NYHA) Class II-IV, under the Brazilian Private Healthcare System perspective. A previously developed cost-effectiveness model based on PARADIGM-HF trial was adapted to Brazil using Latin-American trial subgroup (N=1,433) and Brazil-specific epidemiologic and economic data. A two-state regression-based (Markov) cost-utility model with one-month cycling was utilized to examine a hypothetical cohort of HFrEF patients, predicting events and outcomes (mortality, all-cause hospitalization, adverse events and health-related quality of life), adjusted according to baseline characteristics and time from randomization, for each treatment arm. Quality-adjusted-life years (QALY) were derived from PARADIGM-HF. Costs (BRL) include drug, hospitalization and medical resources estimated for private health sector from 2017. Primary outcome was cost-utility (cost/QALY gained) over a 30-year time horizon. Univariate and probabilistic sensitivity analyses were performed. Base-case results suggest that compared with enalapril, sacubitril/valsartan is associated with incremental costs of BRL17,352 and 0.50 QALYs gained, with an incremental cost-effectiveness ratio of BRL34,729 per QALY gained. Increased costs of pharmacological therapy were offset by reductions in hospitalization costs. All-cause– and cardiovascular mortality estimates were reduced at all time points. Expected survival estimates were greater among patients receiving sacubitril/valsartan versus those receiving enalapril (6.24 vs. 5.67 years). Overall, results were not sensitive to variation in model parameters; results were most sensitive to cardiovascular mortality estimates and treatment-effect duration. The Brazil-adapted model estimates suggest that sacubitril/valsartan represents a cost-effective intervention in the treatment of HFrEF (NYHA Class II-IV) versus enalapril, assuming a willingness-to-pay threshold of 3 times the GDP per capita (1 x GDP 2017: BRL 31,587) per QALY gained. Consequently, sacubitril/valsartan represents a good value for money compared with enalapril under the Private Healthcare System in Brazil.

PSS31 - COST PER RESPONDER OF SECUKINUMAB COMPARED TO OTHER BIOLOGICS IN MODERATE-TO-SEVERE PLAQUE PSORIASIS FROM THE PRIVATE PAYER PERSPECTIVE IN BRAZIL

To estimate the cost per Psoriasis Area and Severity Index (PASI) ≥90 responder of secukinumab as first biologic treatment compared with adalimumab, etanercept, infliximab and ustekinumab over 16 and 52 weeks, and cost per sustained response in 16-week responders up to 52 weeks from the perspective of the Brazilian private healthcare system. A 52-week decision-tree model reflecting response to treatment, defined as PASI reduction of <50%, 50%-74%, 75%-89% and ≥90% was developed. Non-responders patients (PASI<75 at 16 weeks) and patients that discontinued treatment due to other reasons (e.g. adverse events, dropouts) were switched to standard of care. Clinical data inputs of PASI distribution at 4, 8, 12, 16 and 52 weeks were derived from a mixed treatment comparison comparing the biologics to placebo. Annual drug costs were based on the respective ex-factory prices and the number of doses required for 52 weeks. Sensitivity analysis was performed to evaluate the uncertainties of the model. Over 16 weeks, the cost per PASI ≥90 responder of secukinumab (BRL 65,353) was lower than most biologics, except for ustekinumab (BRL 56,638). Secukinumab had the lowest cost per PASI ≥90 responder over 52 weeks (BRL 151,415) compared with ustekinumab (BRL 156,744), adalimumab (BRL 248,203), infliximab (BRL 255,713) and etanercept (BRL 278,183). Likewise, secukinumab had the lowest cost per sustained 52-week PASI ≥90 responder (BRL 82,535) compared with other biologic treatments (range from BRL 98,643 to BRL 136,026). Sensitivity analysis confirmed the favorable results of secukinumab. Secukinumab as first biologic treatment of adults with moderate-to-severe psoriasis is cost-effective, with a lower cost per PASI ≥90 responder compared with other biologic treatments in Brazil from private payer perspective.

PMS20 - BUDGET IMPACT OF INTRODUCING SECUKINUMAB IN THE TREATMENT OF ANKYLOSING SPONDYLITIS FROM THE PRIVATE PAYER PERSPECTIVE IN BRAZIL

To evaluate the budget impact of including secukinumab for the treatment of ankylosing spondylitis (AS) patients from the perspective of the Brazilian private healthcare system. A five-year time horizon excel-based Markov model was developed to estimate the investment required for the inclusion of secukinumab in a hypothetical healthcare plan formulary, by comparing two scenarios: "without secukinumab” versus "with secukinumab". The model assumed the following parameters: a hypothetical population of 1,000,000 individuals in the first year and an annual incidence rate equal to 0.007% from the second year on; AS prevalence of 0.12%; from total AS patients, 35% are eligible for biologic therapy and among them 19.4% are treated with discontinuation rate of 30% for all biologic therapies. Market share of all biologics (adalimumab, certolizumab, etanercept, golimumab, infliximab and secukinumab) were calculated throughout three different assumptions: (A1) In both scenarios, all patients (naïve and biologic-experienced) were distributed equally among all biologics; (A2) Secukinumab as a preferential choice for naïve patients (100%); (A3) Secukinumab as a preferential choice for naïve and biologic-experienced patients who failed to previous biologic treatment (100%). Only drug costs were considered, which were based on the respective ex-factory prices and the recommended dosages. Infliximab cost was also based on an average body weight of 70kg. In this hypothetical healthcare plan population, 105 AS patients would be treated with biologic agents at the end of five years. The total budget impact, due to the introduction of secukinumab in its formulary, was negative in all three assumptions as follows: (A1) –BRL1,92 million; (A2) –BRL3,08 million and (A3) –BRL6,44 million. The introduction of secukinumab in the treatment of ankylosing spondylitis patients could generate savings from the perspective of private healthcare system according to this model, suggesting secukinumab as preferred biologic treatment choice in this market.

Jizzakh Petroleum to build new refinery in Uzbekistan with technology from Honeywell UOP

The first coronavirus disease 2019 (COVID-19) report in Brazil occurs by the end of February, and 4 months later, there was more than 1 million infected patients and 54,971 deaths.The health-care system in Brazil is universal, meaning that all inhabitants are covered by the Unified Health Care System, and 20% of Brazilian citizens are covered by private health-care insurances. In this scenario, the government adopted some actions to combat the pandemics, including guidelines for COVID-19 prevention and management, allocation of funds to support primary care, extension of medical services in primary health units, increase in the number of health-care professionals, distribution of COVID-19 tests, use of telemedicine to monitor patients with flu-like symptoms, and teleconsulting with psychiatrist and psychologists.Since the pandemic offers a unique opportunity for research and management in Brazil, a coalition initiative conducted several therapeutic trials in search of safe treatments for patients with COVID-19. Other issue in this field was the organization of health system, both in private and public organizations.

Cost-effectiveness and budgetary impact of lipegfilgrastim for the reduction of chemotherapy-induced neutropenia in Brazil

Background: Granulocyte-colony stimulating factors (G-CSFs) reduce the risk of chemotherapy-induced neutropenia. Lipegfilgrastim is a long-acting, once-per-cycle G-CSF, while Brazil’s standard of care is short-acting filgrastim. A cost-effectiveness and budget impact analysis of lipegfilgrastim was conducted with filgrastim and once-per-cycle pegfilgrastim for adults at risk of neutropenia in Brazil. Methods: The decision model used national and clinical data to evaluate the costs and outcomes of each treatment. Costs included drug and medical expenses, outpatient and inpatient neutropenia treatments, and adverse events. Health outcomes included incidence of neutropenia-related events. For the budget impact analysis, health outcomes and costs for the pre/post-lipegfilgrastim scenarios were combined to identify expenditure with lipegfilgrastim’s introduction. Results: Total cost per patient during a course of four chemotherapy cycles was estimated at R$12,920 for lipegfilgrastim, R$15,168 for filgrastim, and R$13,232 for pegfilgrastim. Based on better outcomes and lower total costs with lipegfilgrastim compared with filgrastim as well as pegfilgrastim, lipegfilgrastim was the dominant treatment strategy over both filgrastim and pegfilgrastim during the duration of chemotherapy treatment. Over 5 years, the uptake of lipegfilgrastim led to savings of R$61,532,403 in overall medical costs. Neutropenic events decreased by 17,141 and deaths linked to febrile neutropenia decreased by 239. Conclusion: Due to better outcomes and lower overall cost, lipegfilgrastim was a cost-saving strategy compared with filgrastim and pegfilgrastim in the Brazilian healthcare system. Furthermore, the budget impact analysis estimated a reduction in overall medical costs and improved health outcomes over 5 years following the introduction of lipegfilgrastim.

Temporal Trends and Factors Associated with Medication Prescription Patterns in Peritoneal Dialysis Patients.

Patients on peritoneal dialysis (PD) suffer from a high burden of comorbidities, which are managed with multiple medications. Determinants of prescription patterns are largely unknown in this population. This study assesses temporal changes and factors associated with medication prescription in a nationally representative population of patients on PD under the universal coverage healthcare system in Brazil. Incident patients recruited in the Brazilian Peritoneal Dialysis Study (BRAZPD) from December 2004 to January 2011, stratified by prior hemodialysis (HD) treatment, were included in the analysis. Multivariable logistic regression was used to assess the association between medication prescription and socioeconomic factors. Yearly prevalent cross-sections were calculated to estimate prescription over time. Medication prescription was in general higher among patients who had previously received HD, compared with those who started renal replacement therapy (RRT) directly on PD. Prescription increased from baseline to 6 months of PD therapy, particularly in those who did not previously receive HD. After accounting for patient characteristics, significant associations were found between socioeconomic factors, geographic region, and medication prescription patterns. Finally, the prescription of all cardioprotective and anemia medications and phosphate binders increased significantly over time. In a PD population under universal coverage in a developing country, there was an increase in drug prescription during the first 6 months on PD, and a trend toward more liberal prescription of medications in later years. Independent from patient characteristics and comorbidities, socioeconomic factors influenced drug prescriptions that likely impact patient outcome, calling for public health action to decrease potential inequities in management of comorbidities in PD patients.

The long-term costs for treating multiple sclerosis in a 16-year retrospective cohort study in Brazil.

BackgroundMultiple Sclerosis (MS) is a disease that appreciably impacts on the quality of life of patients and is associated with high expenditure. MS is a chronic multifactorial disease, characterized by inflammation, demyelination and axonal loss. The Brazilian public health system provides pharmacological treatment as well as hospital and outpatient care for patients with relapsing-remitting and secondary progressive multiple sclerosis. However, we are not aware of any previous publications assessing total direct medical costs in patients with a long follow-up within the Brazilian healthcare system. Consequently, the objective is to analyze public spending on patients with MS to guide stakeholders in future investment and disinvestment decisions.Methods and findingsWe retrospectively analyzed public Brazilian spending on patients with MS between 2000 and 2015 using the patient-centered registry of all patients in the public health system (SUS) obtained through deterministic-probabilistic record linkage of the Outpatient Information System, Hospital Information System and Mortality Information Systems in Brazil. Descriptive data analysis and a multiple linear regression model was performed to evaluate the associations between the mean annual cost per patient and the clinical and demographic variables. The suitability of the model was verified from a residue analysis and the level of significance adopted was 5%.Results28,401 patients were identified and subsequently 23,082 patients were analyzed. The majority of the patients were female (73.3%), lived in the southeast region (58.9%), had a mean age of 36.8 (± 12.2) years and started treatment using one of the interferons beta (78.9%). The total direct medical cost spending in the sixteen years of the follow-up was US $ 2,308,393,465.60, and the mean annual expenditure per patient was US $ 13,544.40 (± 4,607.05). In the best fit model (p <0.001), approximately 40% of the variability of the mean annual cost per patient was explained by the region of residence; medication used (intention to treat); if the patient was a non-exclusive user of medicines, i.e., used SUS for other procedures other than high-cost medicines; year of treatment start; and presence of events (death; Relapse; change of treatment and/or comorbidity).ConclusionsIn the public health system of Brazil, disease modifying therapies currently represent almost all of the total direct costs of multiple sclerosis treatment. Around the world, new and emerging health technologies to treat of MS impose a challenge to health budgets, highlighting the need for cost-effectiveness studies comparing these technologies to those already available. Our regression model may help in this process, and calls attention to the need to access the real world performance of new therapies available in SUS, with the potential for disinvestment and/ or price reductions if needed.

Outcome of Patients With Breast Cancer Treated in a Private Health Care Institution in Brazil.

PurposeMiddle-income countries like Brazil often have a dichotomous health care system in which patients may be treated in either public or private institutions that differ substantially in terms of level of access to diagnostic and therapeutic procedures.Patients and MethodsThis was a prospective, observational study to assess real-world data in 1,230 female patients with breast cancer who were treated in a private health care institution between 2012 and 2016 in Brazil.ResultsBreast cancer in these patients mostly was diagnosed at early (79.0% stages I or II) or locally advanced (16.1% stage III) stages. The primary tumor was resected in 89.0% of cases, most often through breast-conserving surgery (55.1%). Patients with locally advanced disease received more aggressive therapy (eg, higher rates of mastectomy, axillary dissection and chemotherapy use) than patients with early-stage disease. The estimated 2-year overall survival (OS) was 95.3%. Survival was significantly longer among patients with stage I or II disease (2-year OS, 97.9% and 97.5%, respectively) than those with stage III or IV disease (89.4% and 69.5%, respectively; P < .01). Tumor grade was also correlated with OS in the overall cohort (P = .05); triple-negative status was only prognostic for patients with stage III disease (P < .01).ConclusionThe data provided aid understanding of the current scenario of breast cancer presentation and treatment in the Brazilian private health care system and may serve as a foundation to guide resource allocation. Our results reinforce the need to pursue adequate access to cancer care in low- and middle-income countries to optimize patient outcome.

PCV24 - New Coronary Procedures After Coronary Intervention (PCI ABD CABG) In Brazilian Private Healthcare System: A Rwd Secondary Analysis

PCV24 - New Coronary Procedures After Coronary Intervention (PCI ABD CABG) In Brazilian Private Healthcare System: A Rwd Secondary Analysis