Brazilian Reais Research Articles

Economic Modelling of Screen-and-Treat Strategies for Brazilian Women at Risk of Hereditary Breast and Ovarian Cancer.

BackgroundClinical evidence supports the use of genetic counselling and BRCA1/2 testing for women at risk for hereditary breast and ovarian cancer. Currently, screen-and-treat strategies are not reimbursed in the Brazilian Unified Healthcare System (SUS). The aim of this modelling study was to evaluate the cost effectiveness of a gene-based screen-and-treat strategy for BRCA1/2 in women with a high familial risk followed by preventive interventions compared with no screening.MethodsAdopting the SUS perspective, a Markov model with a lifelong time horizon was developed for a cohort of healthy women aged 30 years that fulfilled the criteria for BRCA1/2 testing according to the National Comprehensive Cancer Network (NCCN) guideline. For women who tested positive, preventive options included intensified surveillance, risk-reducing bilateral mastectomy and bilateral salpingo-oophorectomy. The Markov model comprised the health states ‘well’, ‘breast cancer’, ‘death’ and two post-cancer states. Outcomes were the incremental costs per quality-adjusted life-year (QALY) and the incremental costs per life-year gained (LYG). Data were mainly obtained by a literature review. Deterministic and probabilistic sensitivity analyses were performed to assess the robustness of the results.ResultsIn the base case, the screen-and-treat strategy resulted in additional costs of 3515 Brazilian reais (R$) (US$1698) and a gain of 0.145 QALYs, compared with no screening. The incremental cost-effectiveness ratio (ICER) was R$24,263 (US$21,724) per QALY and R$27,258 (US$24,405) per LYG. Applying deterministic sensitivity analyses, the ICER was most sensitive to the probability of a positive test result and the discount rate. In the probabilistic sensitivity analysis, a willingness to pay of R$25,000 per QALY gained for the screen-and-treat strategy resulted in a probability of cost effectiveness of 80%.ConclusionAlthough there is no rigorous cost-effectiveness threshold in Brazil, the result of this cost-effectiveness analysis may support the inclusion of BRCA1/2 testing for women at high-risk of cancer in the SUS. The ICER calculated for the provision of genetic testing for BRCA1/2 approximates the cost-effectiveness threshold proposed by the World Health Organization (WHO) for low- and middle-income countries.Electronic supplementary materialThe online version of this article (10.1007/s40258-020-00599-0) contains supplementary material, which is available to authorized users.

The High "Cost" of Experimental Drugs Obtained Through Health Litigation in Brazil.

BackgroundBrazilian patients have legal right to access unlicensed medicines undergoing clinical research, if there is evidence of efficacy and safety. This study investigated the occurrence of serious adverse events related to very high-cost medicines from clinical studies, expanded access and compassionate use programs, obtained by patients though health litigation.MethodsA descriptive study using secondary data investigated unlicensed medicines obtained through lawsuits from 2010 to 2017, costing more than 1 million Brazilian reais (BRL), adjusted by the Brazilian Consumer Index to July 2017. Data sources were the Brazilian Health Surveillance Agency Registry (DATAVISA) and Adverse Events in Clinical Studies (NotivisaEC) Databases. Medicines were categorized by the Anatomical Therapeutic Chemical classification to level 03 and events by the WHO Adverse Drug Reaction Terminology. The study received ethical approval by the University of Brasilia Institutional Research Board.ResultsIn the period, 812 drugs were obtained through litigation, and of these, 78 exceeded cost of 1 million BRL; 44 of them presented reports of 1,248 serious adverse events. Total Brazilian Government expenditure with these drugs was 3.2 billion BRL. Class L04A (n=7) showed greater expenditures (over 1.8 billion BRL). One hundred ninety-six deaths occurred and L01X was the most involved category (49.5%). Most other serious events (n=419) and sequelae (n=10) were related to L01X.ConclusionVery high-cost drugs paid for by the government and obtained through health litigation presented deaths and serious adverse events in expanded access and compassionate use programs in Brazil.

PRO8 MEDICATIONS FOR ACROMEGALY: COST-UTILITY AND VALUE OF INFORMATION ANALYSIS

To conduct a cost-utility analysis comparing first- and second-line drug strategies involving octreotide, lanreotide, pasireotide, and pegvisomant for the treatment of patients with acromegaly who have failed surgery, from a Brazilian public health system perspective. A probabilistic cohort Markov model was developed. One-year cycles were employed. The patients started at 45 years of age and were followed lifelong. Costs, efficacy, and quality of life parameters were retrieved from the literature. A discount rate (5% per year) was applied to both costs and effects. Incremental cost-effectiveness ratios (ICERs) were calculated when applicable, and reported as cost per quality-adjusted life year (QALY). Scenario analyses considered alternative dosages, discount rates, tax exemption, and continued use of treatment despite lack of response. Value of information (VOI) analysis was conducted to explore uncertainty and to estimate the costs to be spent in future research. One American dollar (U$) equals approximately 4 Brazilian reais (R$) in 2020. Of the 11 strategies compared, four were not dominated. Only lanreotide autogel showed a reasonable ICER for having its use considered in clinical practice (R$ 112,138/QALY compared to “no treatment”). Considering a threshold of 3 times the GDP per capita (R$ 91,645), lanreotide autogel had a 38.19% probability of being cost-effective compared to “no treatment”. Scenario analyses corroborated the base-case result. VOI analysis showed that much uncertainty surrounds the parameters, and future clinical research should cost less than R$ 43,230,000 per year. VOI also showed that almost all uncertainty that precludes an optimal strategy choice involves quality of life. With current information, the only strategy that can be considered cost-effective in Brazil is lanreotide autogel. No second-line treatment is recommended. Significant uncertainty of parameters impairs optimal decision-making, and this conclusion can be generalized to other countries. Future research should focus on acquiring utility data.

Economic influences of the application of different managements, formulations and doses of Glyphosate on RR soybean

Agricultural practices by farmers in the production system directly affect the economic profitability of crops. The application of glyphosate is one of the most widespread practices on RR soybean crop. However, instead of controlling the problem of weeds in the fields, the practice is sometimes mistakenly employed, damaging the development of RR soybeans, affecting productivity and, consequently, the gross income derived from the culture. So that possible liabilities on RR soybean may be economically quantified, current study analyzes the economic impact caused by the application of glyphosate. Income productivity data of RR soybean with the application of glyphosate were used at different managements, formulations and doses. Experiments were conducted in two distinct regions in the state of Paraná, Brazil, during 2011/2012 and 2012/2013, and rates for a 60-kg soybean sack at an average price of R$ 62.59 (R$ sc-1), between 2011 and 2015, were used to calculate income in Brazilian reais per hectare (R$ ha-1). Results show that profitability of RR soybean crop was reduced when high glyphosate doses were employed, regardless of formulations or managements. Further studies must be undertaken for a more awareness positioning on this technology, with an increase in profitability for soybean producers.

Natural disasters and their costs for healthcare establishments in Brazil, 2000 to 2015

Natural disasters result in impacts on the population's health, damage to healthcare establishments, and, in extreme situations, the health systems' breakdown. National and global trends show an increase in the frequency of disasters associated with climate change. This article aims to analyze the impacts and economic costs of natural disasters for healthcare establishments, identifying the most frequent and costly types and distribution across the Brazilian territory, based on data recorded in Brazil's Integrated Disaster Information System (S2ID) from 2000 to 2015. A total of 15,950 records were systematized and analyzed, of which only 29.4% of the events showed records of costs, totaling nearly BRL 4 billion. Climate disasters were the most frequent, but they did not account for the highest costs. In the cost per event ratio, the costs of hydrological disasters were 3.2 to 3.6 higher than for climate and geologic disasters. Pernambuco, Amazonas, and Santa Catarina were the states with highest total costs in millions of Brazilian reais. The North region, especially the state of Acre, had the highest cost per disaster. Despite the study's limitations (involving the records' quality), the data should be viewed as the tip of an iceberg, since the impacts go beyond the economic damages, impacting the infrastructure and resources that support services, compromising their capacity precisely when the population most needs health services.

Potential life years not saved due to lack of access to anti-EGFR tyrosine kinase inhibitors for lung cancer treatment in the Brazilian public healthcare system: Budget impact and strategies to improve access. A pharmacoeconomic study.

Lung cancer is the fourth most common cancer in Brazil. In the 2000s, better understanding of molecular pathways led to development of epidermal growth factor receptor (EGFR)-targeted treatments that have improved outcomes. However, these treatments are unavailable in most Brazilian public healthcare services (Sistema Único de Saúde, SUS). To assess the potential number of years of life not saved, the budget impact of the treatment and strategies to improve access. Pharmacoeconomic study assessing the potential societal and economic impact of adopting EGFR-targeted therapy within SUS. We estimated the number of cases eligible for treatment, using epidemiological data from the National Cancer Institute. We used data from a single meta-analysis and from the Lung Cancer Mutation Consortium (LCMC) study as the basis for assessing differences in patients' survival between use of targeted therapy and use of chemotherapy. The costs of targeted treatment were based on the national reference and were compared with the amount reimbursed for chemotherapy through SUS. There was no life-year gain with EGFR-targeted therapy in the single meta-analysis (hazard ratio, HR, 1.01). The LCMC showed that 1,556 potential life-years were not saved annually. We estimated that the annual budget impact was 125 million Brazilian reais (BRL) with erlotinib, 48 million BRL with gefitinib and 52 million BRL with afatinib. Their incremental costs over chemotherapy per life-year saved were 80,329 BRL, 31,011 BRL and 33,225 BRL, respectively. A drug acquisition discount may decrease the budget impact by 30% (with a 20% discount). A fixed cost of 1,000 BRL may decrease the budget impact by 95%. Reducing drug acquisition costs may improve access to EGFR-targeted therapy for lung cancer.

On the Brazilian fuel pricing policy: a Gaussian factor model approach

ABSTRACTIn this paper we investigate the oil spot price dynamics and volatility in Brazilian Reais (the local currency). The current policy on price adjustments of refined products caused enormous turmoil in May 2018 due to a trucking strike over high diesel prices. The current price adjustments follow variations of oil prices and exchange rate. This issue opens a discussion of the price transfers of imported oil products. The classic volatility analysis is difficult to carry out because price series in local currency are based on data with non-homogeneous frequency. We use a Gaussian factor model to estimate the oil spot price and then follow two different theoretical approaches to infer the dynamics and volatility in local currency. From these approaches, one can infer how high the volatility is compared to the first future contract taken as a benchmark. Furthermore, one can also monitor the short-term price forecasts once the conditional distribution is known from the dynamics established. This analysis can be applied to any type of refined product depending on the existence of a liquid term structure of future prices.

How does Work Shape Informal Cities

In this paper I will discuss the design of favelas in Brazil. The aim is mainly to highlight how labor can be used as a design tool to address social and economic phenomena shaping the ‘slum’. This will be done by analyzing the informal aspects of ‘slums,’ the rising inequality and rural-urban migration patterns in Brazil. A critical analysis of literature will be compared to empirical data that were personally acquired from Brazilian slums (Cavalcanti, 2016) during the period from 2009 until 2016. Overall, the objective will be to try and consider social aspects within a method of design. Research has shown that favelas have a different land status, different patterns of urban conglomeration and parcelling. However, when compared to formal urban planning the same logic of investment and housing commodification applies. Within favela societies, people sell, use and divide their properties according to noninstitutionalized rules, and their notion of what is shared, public or private is slightly different from that in formal urban planning environments. This leads to a greater presence of tighter, more close-knit communities. A block of houses may be a single house, with various owners sharing it (e.g. villas), the first floor of a house may be for one person and the second for another. In fact, most of the batidas de laje are made for other people (who rent the house, and thus for income generation purposes). The alleys and stairways are public spaces shared by all. Parcelling a house depends on the economic aim or need of a dweller. Finding a piece of land or a house to buy or rent depends on negotiations with the residents of a favela (Cavalcanti, 2009). The right to “verticalizing” depends on the expertise of the masons who are responsible for building the roof and/or the economic resources of the property owner. The need for shelter is considered as a way to acquire land in the outskirts of the favela. The centre is often more expensive, but still targeted by people in need for shelter. Finally, when residents move to vertical or mass housing units they repeat the social practices that they do in the favelas. With the same logic, the price of rent, land and property in favelas is consistently rising, almost proportionately with prices in the cities. Residents generally compare the prices of rent within the favela itself. In 2014, a typical house for rent in a favela (50 m2) would cost 350 Brazilian reais per month (US$106.88)10 in the city of Maceio. In general, this is practically half of what one could ask in a middle class neighborhood within Farol, a neighbourhood where a typical house for rent (50 m2), would cost circa 600 Brazilian reais per month (US$183.22).11 Such discrepancies are slightly higher amongst people who live in big metropolitan areas such as Sao Paulo and Rio de Janeiro, which makes it much more affordable for low-income groups to dwell in slums. In this scenario it may be observed that a capital incursion is developing within favelas: supermarket chains and products are expanding, real estate has arrived: people who received houses from the PAC (Programa de Aceleracao do Crescimento) are illegally selling their tenure for higher prices (Brazil Investment Guide, 2013). Hipsters, creative classes and gringos are moving to favelas, in the process of which they contribute to the gentrification of land and goods. Apart from this, one may note that investment in hotels, museums, social activities, NGOs, UPPs (Unidades de Policia Pacificadora) and other similar activities are constantly increasing. The aforementioned notions express the fine line between considering the favela as an idealistic, unknown dimension with an abstract logic (this is a typical way to romanticize poverty), or stating that favelas are entirely articulated with materialistic and accumulative values. Between seeing the poor as bearers of opportities versus seeing them as heroic entrepreners (Roy, 2005, 148). The difference between these two views should be highlighted and, understanding the importance of labor to residents living in slums highlights these contrasting views from their convergency and divergency, offers a new epistemological frame to study informal settlements that is able to provide a deep insight on the logics of informal settlements. The needs and patterns of favela communities have been studied by the author since 2008. The results of this paper come from an ethnographic study of the Favela Sururu de Capote in Maceio(fig. 3.1-3.2) as well as the social housing that has been conceived to shelter its removed inhabitants in light of the recent Brazilian urban challenges. This research shows how residents’ labor activities have transformed both public spaces and private homes in the favela and how practices of various scales and modes have been contributing to the distribution of urban inequalities and the growth of social informality.

Treatment for human visceral leishmaniasis: a cost-effectiveness analysis for Brazil.

To estimate the cost-effectiveness of strategies for the treatment of VL in Brazil. Cost-effectiveness study comparing three therapeutic options: meglumine antimoniate (MA), liposomal amphotericin B (LAMB) and a combination of LAMB plus MA (LAMB plus MA), from public health system and societal perspectives. An analytical decision-making model was used to compare strategies for the following outcomes: early therapeutic failure avoided at 30days, days of hospitalisation avoided and VL cure at 180days. The efficacy and safety parameters of the drugs came from a randomised, open-label trial and the cost data came from a cost-of-illness study, both carried out in Brazil. For all outcomes analysed, the LAMB strategy was more effective. The MA strategy was inferior to the LAMB plus MA strategy for the outcomes early therapeutic failure avoided and cure. When only LAMB and MA were compared from a societal perspective, a cost of US$ 278.56 was estimated for each additional early therapeutic failure avoided, a cost of US$ 26.88 for each additional day of hospitalisation avoided and a cost of US$ 89.88 for each additional case of cured VL, for the LAMB strategy vs. MA. In Brazil, the LAMB strategy proved to be cost-effective for treating VL, considering a GDP per capita as the willingness-to-pay threshold, for all of the outcomes analysed in comparison to MA.

Cost-effectiveness analysis of the treatment of mild and moderate Alzheimer's disease in Brazil.

Objective:To perform a cost-effectiveness analysis of donepezil and rivastigmine therapy for mild and moderate Alzheimer’s disease (AD) from the perspective of the Brazilian Unified Health System.Method:A hypothetical cohort of 1,000 individuals of both sexes, aged >65 years, and diagnosed with AD was simulated using a Markov model. The time horizon was 10 years, with 1-year cycles. A deterministic and probabilistic sensitivity analysis was performed.Results:For mild AD, the study showed an increase in quality-adjusted life years (QALYs) of 0.61 QALY/21,907.38 Brazilian reais (BRL) for patients treated with donepezil and 0.58 QALY/BRL 24,683.33 for patients treated with rivastigmine. In the moderate AD group, QALY increases of 0.05/BRL 27,414.96 were observed for patients treated with donepezil and 0.06/BRL 34,222.96 for patients treated with rivastigmine.Conclusions:The findings of this study contradict the standard of care for mild and moderate AD in Brazil, which is based on rivastigmine. A pharmacological treatment option based on current Brazilian clinical practice guidelines for AD suggests that rivastigmine is less cost-effective (0.39 QALY/BRL 32,685.77) than donepezil. Probabilistic analysis indicates that donepezil is the most cost-effective treatment for mild and moderate AD.

Healthcare Utilization and Costs Reduction after Radiofrequency Ablation For Atrial Fibrillation in the Brazilian Private Healthcare System.

BackgroundAtrial fibrillation (AF) is the most common arrhythmia worldwide, with significantly associated hospitalizations. Considering its growing incidence, the AF related economic burden to healthcare systems is increasing. Healthcare expenditures might be substantially reduced after AF radiofrequency ablation (AFRA).ObjectiveTo compare resource utilization and costs before and after AFRA in a cohort of patients from the Brazilian private healthcare system.MethodsWe conducted a retrospective cohort study, based on patients’ billing information from an administrative database. Eighty-three adult patients who had an AFRA procedure between 2014 and 2015 were included. Healthcare resource utilization related to cardiovascular causes, including ambulatory and hospital care, as well as its costs, were analyzed. A p-value of less than 0.05 was considered statistically significant.ResultsMean follow-up was 14.7 ± 7.1 and 10.7 ± 5.4 months before and after AFRA, respectively. The 1-year AF recurrence-free rate was 83.6%. Before AFRA, median monthly total costs were Brazilian Reais (BRL) 286 (interquartile range [IQR]: 137-766), which decreased by 63.5% (p = 0.001) after the procedure, to BRL 104 (IQR: 57-232). Costs were reduced both in the emergency (by 58.6%, p < 0.001) and outpatient settings (by 56%, p < 0.001); there were no significant differences in the outpatient visits, inpatient elective admissions and elective admission costs before and after AFRA. The monthly median emergency department visits were reduced (p < 0.001).ConclusionIn this cohort, overall healthcare costs were reduced by 63.5%. A longer follow-up could be useful to evaluate if long-term cost reduction is maintained.

How does Work Shape Informal Cities?

In this paper I will discuss the design of favelas in Brazil. The aim is mainly to highlight how labor can be used as a design tool to address social and economic phenomena shaping the ‘slum’. This will be done by analyzing the informal aspects of ‘slums,’ the rising inequality and rural-urban migration patterns in Brazil. A critical analysis of literature will be compared to empirical data that were personally acquired from Brazilian slums (Cavalcanti, 2016) during the period from 2009 until 2016. Overall, the objective will be to try and consider social aspects within a method of design. Research has shown that favelas have a different land status, different patterns of urban conglomeration and parcelling. However, when compared to formal urban planning the same logic of investment and housing commodification applies. Within favela societies, people sell, use and divide their properties according to noninstitutionalized rules, and their notion of what is shared, public or private is slightly different from that in formal urban planning environments. This leads to a greater presence of tighter, more close-knit communities. A block of houses may be a single house, with various owners sharing it (e.g. villas), the first floor of a house may be for one person and the second for another. In fact, most of the batidas de laje are made for other people (who rent the house, and thus for income generation purposes). The alleys and stairways are public spaces shared by all. Parcelling a house depends on the economic aim or need of a dweller. Finding a piece of land or a house to buy or rent depends on negotiations with the residents of a favela (Cavalcanti, 2009). The right to “verticalizing” depends on the expertise of the masons who are responsible for building the roof and/or the economic resources of the property owner. The need for shelter is considered as a way to acquire land in the outskirts of the favela. The centre is often more expensive, but still targeted by people in need for shelter. Finally, when residents move to vertical or mass housing units they repeat the social practices that they do in the favelas. With the same logic, the price of rent, land and property in favelas is consistently rising, almost proportionately with prices in the cities. Residents generally compare the prices of rent within the favela itself. In 2014, a typical house for rent in a favela (50 m2) would cost 350 Brazilian reais per month (US$106.88)10 in the city of Maceió. In general, this is practically half of what one could ask in a middle class neighborhood within Farol, a neighbourhood where a typical house for rent (50 m2), would cost circa 600 Brazilian reais per month (US$183.22).11 Such discrepancies are slightly higher amongst people who live in big metropolitan areas such as São Paulo and Rio de Janeiro, which makes it much more affordable for low-income groups to dwell in slums. In this scenario it may be observed that a capital incursion is developing within favelas: supermarket chains and products are expanding, real estate has arrived: people who received houses from the PAC (Programa de Aceleração do Crescimento) are illegally selling their tenure for higher prices (Brazil Investment Guide, 2013). Hipsters, creative classes and gringos are moving to favelas, in the process of which they contribute to the gentrification of land and goods. Apart from this, one may note that investment in hotels, museums, social activities, NGOs, UPPs (Unidades de Polícia Pacificadora) and other similar activities are constantly increasing. The aforementioned notions express the fine line between considering the favela as an idealistic, unknown dimension with an abstract logic (this is a typical way to romanticize poverty), or stating that favelas are entirely articulated with materialistic and accumulative values. Between seeing the poor as bearers of opportities versus seeing them as heroic entrepreners (Roy, 2005, 148). The difference between these two views should be highlighted and, understanding the importance of labor to residents living in slums highlights these contrasting views from their convergency and divergency, offers a new epistemological frame to study informal settlements that is able to provide a deep insight on the logics of informal settlements. The needs and patterns of favela communities have been studied by the author since 2008. The results of this paper come from an ethnographic study of the Favela Sururu de Capote in Maceió(fig. 3.1-3.2) as well as the social housing that has been conceived to shelter its removed inhabitants in light of the recent Brazilian urban challenges. This research shows how residents’ labor activities have transformed both public spaces and private homes in the favela and how practices of various scales and modes have been contributing to the distribution of urban inequalities and the growth of social informality.

Propensity score matching comparison of laparoscopic versus open surgery for rectal cancer in a middle-income country: short-term outcomes and cost analysis

BackgroundLaparoscopic surgery for rectal cancer is associated with improved postoperative outcomes compared to open surgery; however, economic studies have yielded contradictory results. The aim of this study was to compare the clinical and economic outcomes of laparoscopic versus open surgery for patients with rectal cancer.MethodsPropensity score matching analysis was performed in a retrospective cohort of patients who underwent elective low anterior resection for rectal cancer treatment by laparoscopic and open surgery in a single Brazilian cancer center. Matched covariates included age, gender, body mass index, pTNM stage, American Society of Anesthesiologists score, type of anesthesia, neoadjuvant chemoradiotherapy, and interval between neoadjuvant chemoradiotherapy and index surgery. The clinical and economic outcomes were evaluated. The follow-up period was within 30 days of the index procedure. The clinical outcomes were reoperation, postoperative complications, operative time, length of stay in the intensive care unit, and postoperative hospital stay. For economic outcomes, a cost analysis was used to compare the costs.ResultsInitially, 220 patients were evaluated. After propensity score matching, 100 patients were included in the analysis (50 patients in the open surgery group and 50 patients in the laparoscopic surgery group). There were no differences in patients’ baseline characteristics. Operative time was longer for laparoscopic surgery (247 minutes vs 285 minutes, P=0.006). There were no significant differences in other clinical outcomes. The hospital costs were similar between the two groups (Brazilian reais 21,233.15 vs Brazilian reais 21,529.28, P=0.115), although the intraoperative costs were higher for laparoscopic surgery, mainly owing to the surgical devices and the theater-related costs. The postoperative costs were lower for laparoscopic surgery, owing to lower intensive care unit, ward, and reoperation costs.ConclusionLaparoscopic surgery for rectal cancer is not costlier than open surgery from the health care provider’s perspective, since the intraoperative costs were offset by lower postoperative costs. Open surgery tends to have a longer length of stay.

Backtesting Basel III: evaluating the market risk of past crises through the current regulation

ABSTRACTAre the recommendations from the Bank for International Settlements (BIS) effective to a broad set of financial crises? We submitted two of the main Basel III recommendations for market risk to a back test: the capital requirements and the Value at Risk (VaR) methodology that includes the BIS’s Stressed VaR. We tested the main Brazilian currency exchange (U.S. Dollar to Brazilian Reais) and currency exchange swaps contracts through volatility-based VaR methodologies in the period that comprises the so-called Brazilian confidence crisis, which occurred in the second half of 2002.While the Stressed VaR revealed inapplicable, due to historical data shortage, the capital requirements level appeared innocuous, due to the high levels of daily volatility – daily oscillation limits may have a significant role on crisis mitigation. To circumvent the lack of either historical information or optimal window for stress patterns, we suggest to calibrate the Stressed VaR or the recently announced Expected Shortfall with a historical VIX (Volatility Index, Chicago Board Options Exchange), working as a volatility scale. We suggest modelling with other densities, apart from the BIS recommended standard normal.

A disclosure of social and environmental results/economy resulting from the implementation of reverse logistics and final disposal of the post‐consumption product: The case of computer peripherals industry

AbstractThis research was conducted with the objective of determining and evidencing the social and environmental/economic results from the implementation of a reverse logistics program providing for the recycling, reuse, and, when necessary, final, environmentally correct disposal of post‐consumption products and product wastes by a multinational manufacturer of computer peripherals with an operation based in the city of São Paulo, Brazil. The reverse logistics process (logisticareversa, or, in this paper, LR) was intended to meet the objectives and principles of the regulatory framework defined in the National Solid Waste Policy (PNRS) in Brazil. A single case study was carried out. The results showed that after the adoption of the solid waste management policy, the study company no longer disposed of 1,413,552 kilograms (kg) of materials classified as mixed iron, polystyrene, cardboard, toner powder, and plastic in landfills. The LR process made a profit in two companies: the company surveyed made, in Brazilian reais (R), R$ 9,188,185.51, and the company contracted to carry out the process made, R$ 411,325.97. This latter profit is called by us the “social profit.” The measurement of the environmental/economic, social, and financial results by internalizing the expenses of the LR program into the costs of production shows that reuse and recycling better meets the needs of society and the company than landfilling these post‐consumption materials. Furthermore, the use of cost accounting allows the verification of other goals not indicated in the current model, such as the generation of employment, income, mitigation of environmental problems, and the profit earned by the company contracted to implement the LR process. We also conclude that cost accounting makes it possible to obtain necessary information for decision makers, who are seeking to neutralize environmental impacts and promote sustainable development, thus harmonizing the economic, social, and environmental aspects, to understand the impacts of the LR process.

Financial and risk analysis of African mahogany plantations in Brazil

ABSTRACT Wood demand is increasing in quality and quantity, and economic studies are fundamental to analyze the feasibility of forest projects. These researches are in line with management and silvicultural studies, highlighting growth and yield modeling. This paper proposes an economic evaluation of implementation of African mahogany stands in Brazil under different perspectives of forest management. Data are from plantations ranging from 1.1 to 15 years old in different Brazilian regions. Financial analysis was undertaken using Net Present Value (NPV), Internal Rate of Return (IRR) and Equal Annual Equivalent (EAE) for a 20-year period considering three thinning management regimes (A - unthinned, B - one thinning at age 10 years remaining 150 trees ha-1 and C - two thinnings, first at age 8 remaining 150 trees ha-1 and second at age 15 years remaining 75 trees ha-1) considering an initial density of 278 trees ha-1. A Monte Carlo simulation was performed considering six risk variables. Results showed that the discount rate is the variable that most influences the viability of the project. All site indexes in all management regimes lead to a feasible financial return, with NPV values ranging from 25,053 to 125,780 Brazilian reais per hectare, being regimes B and C the best ones. The probability for an unfeasible investment is almost zero, highlighting African mahogany as a great forest investment opportunity, providing high interest rates values (14% to 25%), superior to most available market rates of return.

PP163 The Cost-Reimbursement Mismatch For Heart Transplant In Brazil

Introduction:There is an important mismatch in the number of heart transplants performed and the patients in need of a new heart in Brazil, despite a large public transplant program providing universal health coverage for organ transplantation. It is unclear whether the limited number of heart transplants could be related to the high costs of the procedure and potential underpayment from public agencies. We sought to investigate costs of heart transplant in Brazil from the perspective of a transplant center and to compare results to the values reimbursed by the public health system.Methods:All adult heart transplants performed in an academic center from Jul/2015-Jul/2017 were reviewed. Both absorption costing and time driven activity based costing techniques were used to detail costs related to the transplant index admission. Patients’ electronic records were reviewed, involved professionals were interviewed, and the hospital electronic system was queried. Costs associated with infrastructure, personnel, surgical materials, medications, laboratory and imaging were calculated. Brazilian Reais were converted to US Dollars using 2016 purchasing power parity data from OECD.Results:All 27 patients who underwent heart transplants in the time period were included. Survival at 30 days was 94 percent. Average and median cost for the transplant admission was USD 62,336.27 and USD 47,105.52, respectively, while the current reimbursement value is USD 29,675. The lowest cost accrued by the hospital was USD 21,568.90, while the highest was over USD 300,000. Almost 70 percent of costs were related to personnel and hospital structure and not to direct consumption of medications, exams or materials. Total cost was highly dependent on the length-of-stay, particularly days spent in intensive care units.Conclusions:The value currently reimbursed by the public system in Brazil for heart transplants is below the average costs for the procedure in a reference center. This large cost-reimbursement mismatch might limit the increase in the number of transplants that is needed to meet current demands.

International cooperation: drugs donated by the Brazilian government, 2005-2016Cooperación internacional: donaciones de medicamentos del gobierno brasileño entre el 2005 y el 2016

RESUMOObjetivo.Fazer um levantamento acerca das doações internacionais de medicamentos pelo governo brasileiro de 2005 a 2016, identificando o número de unidades de medicamentos doadas e o montante financeiro que esse volume representa.Métodos.Estudo descritivo e exploratório utilizando análise de dados secundários disponíveis no Sistema de Gestão de Materiais do Ministério da Saúde (SISMAT). Foram levantadas informações sobre país solicitante, ano da doação, medicamento, número de unidades farmacêuticas doadas e valor correspondente (em reais).Resultados.No período estudado, 66 554 892 unidades de medicamentos foram doadas, correspondendo a 84 371 308,72 reais (25 505 235,70 dólares). Foram doados medicamentos para Angola, Benin, Bolívia, Burkina Faso, Cabo Verde, Colômbia, Costa do Marfim, Cuba, El Salvador, Equador, Guatemala, Guiana, Guiné Bissau, Haiti, Honduras, Líbia, Moçambique, Nicarágua, Paraguai, Peru, República Dominicana, São Tomé e Príncipe, Síria e Suriname, países do Mercado Comum e Comunidade do Caribe (CARICOM) e Organização Pan-Americana da Saúde (OPAS). Não foi detectado nenhum padrão de distribuição em termos quantitativos. Picos no número de medicamentos doados ocorreram em 2008, 2011 e 2012, com maior número de países contemplados em 2006 e 2012 (13 e 14 países, respectivamente). Foram doados medicamentos para HIV/Aids, malária, leishmaniose, diabetes, cólera, esquistossomose, tuberculose, gripe influenza, doenças oportunistas, imunizações, suporte nutricional e calamidade pública.Conclusões.Em grande medida, os medicamentos doados foram antimicrobianos utilizados para tratamento de doenças tropicais negligenciadas. Estudos adicionais são sugeridos para correlacionar intervenções de saúde pública com as doações de medicamentos, como forma de promover o desenvolvimento econômico sustentável dos países beneficiários.

Who are the individuals diagnosed with epilepsy using the Public Health System in the city of Pelotas, southern Brazil?

The aim of this study was to describe sociodemographic, clinical, behavioral, nutritional, and health-related variables from people with epilepsy. A descriptive observational study was carried out in the city of Pelotas, southern Brazil. Sociodemographic, clinical, behavioral, nutritional, and health-related variables were collected. A univariate analysis was performed, calculating the measures of central tendency for continuous variables and proportions for categorical ones. The sample consisted of 101 people, age ranging from 12 to 75years, mostly male (50.5%) and white (59.4%). Only 37.2% from the sample was employed, and the average income was R$ 788.00 Brazilian Reais (US$ 245.90 at the moment of the interview). From all the subjects, 65.6% was in treatment with monotherapy, 62.9% presented more than 15 seizures during the life, 67.3% showed active epilepsy, 64.6% were physically inactive, 52.5% presented normal body mass index, and 50% showed generalized seizures. The most used antiepileptic drug was the carbamazepine. The average score of depression was 12.6±4.1 points and 34.6% showed severe depressive symptoms (equal or higher than 15 points). The mean score of trait and state anxiety was 12.2±3.6 and 15.1±3.4 points, respectively (ranging from 6 to 24 points). The mean score of quality of life and stress was 63.2±18.2 (ranging from 0 to 100 points) and 21.2±7.1 points (ranging from 0 to 40 points), respectively. Considering the medication side effects, the mean score was 42.4±8.9 points, 38.5% showing high rates (higher than 45 points), and only 16% showing good sleep quality. In conclusion, these results are important to improve understanding of these individuals' disease and to subsidize the specific public policies in countries of low and middle income.

Measure nicotine dependence by the fagerström test for nicotine dependence

ABSTRACT Objective To assess the level of nicotine dependence of smokers in a university dental clinic in southern Brazil using the Fagerström Test for Nicotine Dependence and identify those who would like to quit smoking. Methods A cross-sectional study was carried out with 93 Dental School patients, who underwent a face-to-face interview with four researchers. Data was analysed using descriptive statistics and the Chi-Square test with a significance level of 5%. Results The mean age of the smokers was 47.90 and most had had up to eight years of schooling, and had a family income of less than 1,000 Brazilian Reais. The degree of nicotine dependence was classified, by the mean, 4.45 ± 2.53 points (±SD). There was a significant correlation between nicotine dependence and the number of cigarettes smoked per day. Conclusion The 1% sodium hypochlorite solution caused least damage to the denture structure, not leading to decrease of the superficial microhardness.