Brazilian Health System Research Articles

Cost–Utility Analysis of Supervised Inspiratory Muscle Training Added to Post-COVID Rehabilitation Program in the Public Health System of Brazil

Objectives: This study aims to provide model-based cost–utility estimates for the addition of inspiratory muscle training (IMT) in COVID-19 pulmonary rehabilitation (PR). Methods: A cohort model comparing IMT with PR (intervention group) to IMT with only PR (control group) was used. The payer perspective from the Unified Health System in Brazil was adopted. Effectiveness parameters: Effectiveness was measured in quality-adjusted life years (QALYs). Probabilistic sensitivity analyses were performed using 1000 Monte Carlo simulations. A beta probability distribution was assumed for utilities, and a gamma distribution was applied to the costs. A cost-effectiveness threshold of BRL 40.000/QALYs was applied. Results: As the threshold of BRL 40.000/QALYs, we obtained 512 (51.2%) simulations that can be considered cost-effective to IMT added in PR programs. IMT added in PR treatment was more expensive (USD 317.73 versus USD 293.93) and more effective (incremental utility of 0.03 to INT group) than PR alone. The incremental cost-effectiveness ratio (ICER) was 793.93 USD/QALY. Conclusions: IMT added to PR is a cost-effective alternative compared with PR for post-COVID-19 patients. This strategy may result in net cost savings and improvements in the QALYs for these patients.

Effects of an Exercise and Lifestyle Education Program in Brazilians living with prediabetes or diabetes: study protocol for a multicenter randomized controlled trial.

Patient education is a crucial strategy for promoting prevention and diabetes self-management since glycemic control achievement involves taking medications, medical nutrition therapy, physical exercise, and behavior changes. However, patient education programs are still barely implemented in low- and middle-income countries. This trial aims to investigate whether a lifestyle education intervention added to physical exercising is superior to sole physical exercising regarding functional capacity, disease-related knowledge, health behaviors, cardiometabolic health parameters, quality of life, depression, and diet quality in individuals with prediabetes or diabetes. Multicenter double-blinded randomized controlled trial with two parallel arms involving 12-week intervention and 6-month follow-up. The eligible individuals (≥ 18years, living with prediabetes or diabetes, literate, no clinical decompensation and/or physical and/or mental limitations that contraindicate physical exercising, written physician permission for exercise, no cognitive impairment, no vision limitations for reading, no confirmed diagnosis of unstable coronary disease or heart failure, no pacemaker and/or implantable cardioverter-defibrillator, no complex ventricular arrhythmias, no intermittent claudication, no recent cardiovascular event or cardiac surgery, and no currently enrolled in a structured exercise program) were recruited from two Brazilian cities and randomized to either (1) an Exercise and Lifestyle Education Program (ExLE) or (2) an Exercise Program (Ex), which can be delivered on-site or remotely based on the participants' internet access and technology literacy. The primary outcomes will be changes in functional capacity and disease-related knowledge. The secondary outcomes will involve changes in health behaviors (health literacy, physical activity level, exercise self-efficacy, and medication adherence) and cardiometabolic health parameters (glycemic control, anthropometric measures, and cardiac autonomic control). Program adherence, satisfaction with the program, diabetes-related morbidity, and changes in quality of life, depression, and diet quality will be the tertiary outcomes. Assessments will occur at baseline, post-intervention, and after 6-month follow-up. If superior effectiveness of ExLE compared to Ex program to improve the outcomes measures is found, this program could be delivered broadly in the Brazilian health system, especially in the primary care facilities where most individuals living with prediabetes and diabetes in our country are assisted. ClinicalTrials.gov, NCT03914924 . Registered on April 16, 2019.

Market concentration of the Brazilian hospital medical supplementary health system

BackgroundThe Brazilian supplementary health market has undergone transformations in recent years due to constant mergers and acquisitions of by large corporations, contributing to the increase in market concentration, especially in the poorest and least developed regions of the country. Thus, given the care it provides and its economic relevance, understanding the fundamentals of these movements, the likely consequences and trends for the health market are relevant, important, and strategic.ObjectiveTo understand the general and specific context of Brazilian supplementary health, its scenarios, and trends, with emphasis on the analysis of market concentration and recent mergers and acquisitions.MethodologyThe research is applied, descriptive and exploratory and uses secondary data from various sources, submitted to quantitative data analysis methods. The data are organized into three groups: historical and regulatory documents; industry data; and market.ResultsThe results show the growing concentration of the market promoted by large publicly traded corporations, the growing relevance of tech startups on the healthcare landscape, the predominant use of the relative valuation model, with implicit multiples for asset pricing and the prevalence of corporate health plans.ConclusionThe growing concentration of the system projects a market with fewer options and less competitiveness, since the growth of large operators is evident, in addition to the relevant increase in the number of complaints from users of the system, which signals the growing gap between the expectations of users and the levels of quality care offered. The study also highlights the predominance of corporate health plans, revealing the direct relationship between access to supplementary health services and employability rates. The analysis of M&A operations, in addition to the increase in market concentration, reveals the prevalence of the use of the relative valuation model and implicit multiples for the pricing of traded assets. This denotes the future expectation of wealth generation, at least equivalent to the historical series of the sector, on the part of investors, whose frustration may signal the decreasing attractiveness of resources and M&A operations in the sector in the coming years.

Cost-benefits of parenteral nutrition read to use bags versus production in the pharmacy in Brazilian health system

Cost-benefits of parenteral nutrition read to use bags versus production in the pharmacy in Brazilian health system

ReflACTION framework: A proposed model for implementation of clinical pharmacy services

The implementation of clinical pharmacy services (CPS) has grown worldwide. However, few studies have used models and/or frameworks to facilitate the implementation process, especially in a low and middle-income countries. In addition, there are limitations in the ways that implementation frameworks are used. Therefore, this discussion aimed to propose and describe an approach using the ReflACTION framework. ReflACTION emerged from several years of systematic observation and experience of the Laboratory of Teaching and Research in Social Pharmacy (LEPFS) in implementing CPS in different settings of Brazilian health system. These experiences led the research group to systematize the implementation of CPS based on three theorical references: Paulo Freire's theoretical references, the Maguerez Arc and the Apoteca framework. The ReflACTION framework proposes five steps that starts and ends in the setting, which are: observation of reality; gathering key-points; theorization; solution hypothesis; and application to reality. All steps were carried out considering the determinants of the implementation process. For the present study, we highlight the importance of the implementation team, the involvement of stakeholders as well as their dialogue and awareness. Thus, we describe the operationalization process for each step. The ReflACTION framework can be used to describe and guide the implementation process of CPS. We expect the proposed framework may add knowledge to implementation science and, ultimately, achieve desired patient outcomes.

Building a National Policy for Rare Disease in Brazil.

Rare diseases (RD) are individually rare, although encompass a significant proportion of the population, affecting not only the individuals but also their families. In Brazil RD is defined by the Ministry of Health as a disorder that affects up to 65 individuals in 100,000, or 1.3 individuals in every 2,000. In this review the environment that led to the publication of a National Policy for Comprehensive Care for People of Rare Disease in 2014, a national plan with the aim to decrease morbidity and mortality of RD, improving the care of people with RD in the public health system are described. The process that finally led to such policy took over a decade, moving forward not only due to technical needs, but having patient organizations as essential actors and advocates. Specialized centers in RD were licensed and, since its publication, 33 centers have been accredited; such process, however, has been slow and concentrated in specific regions and larger cities of the country. Despite the incorporation of genetic tests in 2014 and exome sequencing later in 2020, many genetic tests are not offered by specialized centers, with unequal availability across the country. Public health system in Brazil uses ICD-10 for disease coding, preventing appropriate epidemiologic knowledge of RD in Brazil. Incorporation of new technologies as orphan drugs has been in place and regulation for expedite licensing for new RD drugs were issued, although high cost and availability to RD population has been a challenge.

Prevalence and genotype distribution of human papillomavirus (HPV) in penile cancer in Brazil

Objective: To estimate the prevalence and genotypic distribution of Human Papillomavirus (HPV) in penile cancer in Brazil. Methods: This is a systematic review and meta-analysis of studies published from 2000 to 2021, that investigated the prevalence and genotypic distribution of HPV in penile cancer in different geographical regions in Brazil, using molecular methods. The review was registered in the International Prospective Register of Systematic Reviews (PROSPERO), conducted in accordance with the Preferred Reporting of Systematic Reviews and Meta-Analysis Statement (PRISMA) and the quality of included studies was assessed by the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Studies Reporting Prevalence Data. Results: 15 studies were included, comprising 1,250 cases. The combined prevalence of HPV in penile cancer was 52.0% and the highest prevalence was observed in the Northeast region (79%), followed by the North region (54%), Southeast (44%) and Central-West region (31%). HPV16 was the most prevalent genotype, followed by HPV6, HPV11, HPV18, HPV51, HPV59, HPV74, HPV31, HPV35 and HPV68. Final considerations: Our results confirm the association of HPV with penile cancer and highlight the presence of viral genotypes not covered by the tetravalent prophylactic vaccine distributed by the public health system in Brazil.

KRT in Brazil: A Retrospective Cohort Study Based on Analysis of the Brazilian Public Health System.

Brazil has the largest Public Health System providing universal coverage for chronic dialysis. The objective was to describe the number, sociodemographic, and clinical characteristics of patients undergoing kidney replacement therapy (KRT) by dialysis within the Public Health System in Brazil. We carried out a retrospective cohort study analyzing the database from the Brazilian Public Health System, focusing on procedures related to KRT. The study encompassed both prevalent and incident patients who underwent KRT in Brazil between 2015 and 2023. We observed an increase in the number and prevalence rate of dialysis patients from 2015 to 2023. We also noticed an increase in the age at dialysis initiation and in the prevalence of mixed-race patients and a reduction in the proportion of those undergoing peritoneal dialysis and with arteriovenous fistula. We identified an upward trajectory in the values of single-pool Kt/V over the years, contrasting with a decline in hemoglobin levels. The overall estimated prevalence rate of dialysis patients increased from 654 per million population (pmp) to 792 pmp over the years. The survival rates of incident KRT patients at 12 and 96 months were 81% and 60%, respectively. We reported an increase in the age at which dialysis began and a decline in the adoption of peritoneal dialysis over the years. While there have been some improvements over the years resulting in better adequacy of hemodialysis as measured by Kt/V, controlling certain parameters such as hemoglobin levels has remained challenging.

Inequality in financial risk protection in health among displaced populations: The case of Venezuelan women in Brazil

ObjectiveWorsening economic and social conditions in Venezuela have forced many to migrate. Women and girls are particularly at risk of health vulnerability in this context. This study examines healthcare expenditure and financial risk protection inequalities among Venezuelan migrant women in Brazil. MethodsWe conducted a survey of 2012 Venezuelan women aged 15–49 who migrated to Brazil between 2018 and 2021. We estimated and decomposed concentration indices to analyse inequalities in out-of-pocket healthcare expenditures (OOPHE) and catastrophic health expenditures (CHE) across the entire socioeconomic distribution. We applied Blinder-Oaxaca decompositions to explain differences in healthcare spending between migrant and Brazilian women. ResultsVenezuelan migrant women displayed noticeable disparities in OOPHE and incidence of CHE. Approximately half of our sample of migrants reported no income, no expenditures, and hence no CHE. OOPHE and CHE incidence were concentrated among less poor migrant women, whilst for Brazilian women, CHE was concentrated among the poorer. Location, time since arrival to Brazil, higher education, and income were key contributors to socioeconomic inequality in OOPHE and CHE for migrants. The main explanatory factor for differences in OOPHE between migrants and non-migrants was differences in income profiles. ConclusionsAddressing financial risk protection in health is crucial for displaced populations, especially women and girls. While the public health system in Brazil offers universal healthcare coverage in principle, our results suggest that there is still a significant risk of lack of access to healthcare for Venezuelan migrant women, which may be driven by insufficient financial means.

Wound-healing properties of Stryphnodendron adstringens (barbatimão) in skin and mucosa injuries: a scoping review protocol.

This review will map the literature on the types of research and methods used to investigate the wound-healing properties of Stryphnodendron adstringens ( barbatimão ) in skin and mucosa injuries. Barbatimão is a Brazilian native plant and its wound-healing properties have been described in literature since the colonial period. It is one of the 71 plants included in the Brazilian health system's national list of medicinal plants of interest. However, existing literature reviews on the subject are limited, not comprehensive, lack a search strategy, and lack peer review. This scoping review will include all types of published and unpublished sources that investigate the wound-healing properties of barbatimão to treat any type of skin or mucosa injury in humans, animals, or in vitro, in any context. A scoping review will be conducted following JBI methodology. The main databases to be searched will include Embase (EBSCOhost), CINAHL (EBSCOhost), Scopus, PubMed (EBSCOhost), ScienceDirect, Lilacs, SciELO, CUIDEN, MOSAICO, Web of Science, Epistemonikos, and Google Scholar. Unpublished studies will also be considered. Two independent reviewers will examine titles and abstracts and select and read full-text sources for possible inclusion. Subsequently, the reviewers will extract and synthesize the data, which will be presented as a map, diagram, or table, according to the review objectives. Open Science Framework osf.io/w57m4.

Custo-Efetividade da Oxigenação por Membrana Extracorpórea Venoarterial no Choque Cardiogênico Refratário: Um Estudo na Perspectiva Brasileira

Abstract Background Refractory cardiogenic shock (CS) is associated with high mortality rates, and the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a therapeutic option has generated discussions. Therefore, its cost-effectiveness, especially in low- and middle-income countries like Brazil, remains uncertain.Objectives: To conduct a cost-utility analysis from the Brazilian Unified Health System perspective to assess the cost-effectiveness of VA-ECMO combined with standard care compared to standard care alone in adult refractory CS patients. Methods We followed a cohort of refractory CS patients treated with VA-ECMO in tertiary care centers located in Southern Brazilian. We collected data on hospital outcomes and costs. We conducted a systematic review to supplement our data and utilized a Markov model to estimate incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) and per life-year gained. Results In the base-case analysis, VA-ECMO yielded an ICER of Int$ 37,491 per QALY. Sensitivity analyses identified hospitalization cost, relative risk of survival, and VA-ECMO group survival as key drivers of results. Probabilistic sensitivity analysis favored VA-ECMO, with a 78% probability of cost-effectiveness at the recommended willingness-to-pay threshold. Conclusions Our study suggests that, within the Brazilian Health System framework, VA-ECMO may be a cost-effective therapy for refractory CS. However, limited efficacy data and recent trials questioning its benefit in specific patient subsets highlight the need for further research. Rigorous clinical trials, encompassing diverse patient profiles, are essential to confirm cost-effectiveness and ensure equitable access to advanced medical interventions within healthcare systems, particularly in socio-economically diverse countries like Brazil.

Reframing goals and strategies for delivering humanized obstetric care in Brazil

Introduction: Despite the long-lasting efforts to promote the quality of obstetric care, Brazil requires robust changes in the care practices throughout the prenatal-labour-postpartum continuum. The ongoing National Program for the Humanization of Prenatal and Childbirth (PHPN) efforts address the fight against obstetric violence (OV), the improvement in the quality of obstetric care, but its implementation has faced obstacles and difficulties, such as responding to cultural values and operating with a weak infrastructure. This research explored Brazilian health and social service professionals’ perceptions of the PHPN’s recommendations regarding innovation, policy and practice changes necessary to respect women’s human rights to receive a high quality, dignifying obstetric care. Methods: An online multi-site survey in which data were collected (Jun 2019-Mar 2020) from health professionals working in the public health system in Brazil. Data analysis used descriptive statistics and thematic analysis. Analytical themes were Perceptions of Program effectiveness to minimize obstetric violence and Program’s gaps, inadequacies and needed changes. Results: Respondents (n=369) disclosed their perceptions about the Program’s nature, utility, and gaps towards an improved implementation. Key issues were rooted in the outdated university education, reduced accountability, and governance in services’ management; unfavourable work conditions and climate; professional power-imbalance; population’s lack of information about the Program; underutilization of obstetric nurses’ and midwives’ skills; neglect of professional development; no denunciation & re-education, and culture of quality improvement. Conclusions: Firmness, hope and determination will be needed to transform society’s culture of silence about OV, awakening the public awareness and mobilizing to enhance collective health and political literacy to ensure professional accountability while protecting women and newborns. There is a need for a realignment of work processes, an investment in professional education, and education within women’s social networks for women to become partners in the active process of improvement of quality of obstetric care.

A multicentre study of amphotericin B treatment for histoplasmosis: assessing mortality rates and adverse events.

Progressive disseminated histoplasmosis is a significant issue in Latin America, particularly in Brazil, contributing to high mortality rates. Our objectives were to comprehensively describe histoplasmosis treatment with various amphotericin B (AmB) formulations, including mortality rates, adverse effects and risk factors for mortality. This multicentre retrospective cohort study (January 2014-December 2019) evaluated medical records of patients with proven or probable histoplasmosis treated with at least two doses of AmB in seven tertiary medical centres in Brazil. We assessed risk factors associated with death during hospitalization using univariate and multivariate analyses. The study included 215 patients, mostly male (n = 158, 73%) with HIV infection (n = 187, 87%), and a median age of 40 years. Only 11 (5%) patients initiated treatment with liposomal amphotericin B (L-AmB). Amphotericin B deoxycholate (D-AmB) was administered to 159 (74%) patients without changes in the treatment. The overall mortality during hospitalization was 23% (50/215). Variables independently associated with mortality were use of D-AmB (OR 4.93) and hospitalization in ICU (OR 9.46). There was a high incidence of anaemia (n = 19, 90%), acute kidney injury (n = 96, 59%), hypokalaemia (n = 73, 55%) and infusion reactions (n = 44, 20%) during treatment. We found that D-AmB was the main formulation, which was also associated with a higher mortality rate. Lipid formulations of AmB have become more readily available in the public health system in Brazil. Further studies to evaluate the effectiveness of L-AmB will likely show improvements in the treatment outcomes for patients with disseminated histoplasmosis.

Impact of COVID-19 Pandemic on Cleft Lip/Palate Surgery in Brazil: Assessing the Current Landscape.

This study aims to evaluate the impact of COVID-19 and the current situation for cleft lip/palate treatment surgeries within Brazil's public health system. Our retrospective study analyzed CL/P corrective surgeries in Brazil's health system using DATASUS TabNet data from March 2020 to December 2022, with historical data from January 2016 to February 2020. We employed ARIMA analysis to estimate pandemic-related surgery cancellations. In 2020, 1992 (CI 95%: 989-2995) CL/P surgeries were not conducted due to pandemics, a 44.1% (CI 95%: 28.1-54.2%) decrease compared to expectations for march to December 2020. Between the onset of the pandemic in Brazil and the end of 2022, 10,643 surgeries were performed in the country, representing a 33.8% shortfall compared to the expected number for the period (16,076; 95% CI: 9697-22,456). The study highlights COVID-19's impact on CL/P surgeries in Brazil. Post-pandemic, surgeries increased but regional disparities remain, urging collaborative efforts to improve services and support affected patients.

Sex Disparity in Stroke Mortality among Adults: A Time Series Analysis in the Greater Vitoria Region, Brazil (2000-2021).

The disparity between the sexes in stroke mortality has been demonstrated in people from different locations. The objective of this study was to analyze the disparity between sexes in stroke mortality in adults in the metropolitan area of Greater Vitoria between 2000 and 2021. Ecological time series design was conducted with a database of the Brazilian Health System Informatics Department. The annual percentage change and average annual percentage change were calculated through joinpoint regression. Pairwise comparisons using parallelism and coincidence tests were applied to compare temporal trends between men and women. Men had higher mortality rates in most years between 2000 and 2021. In contrast, women had higher proportional mortality values in all years evaluated from 2000 to 2021. The paired comparison revealed a disparity between the sexes in the proportional mortality time series (parallelism test: p = 0.003; coincidence test: p < 0.001). However, the time series of the mortality rates showed no disparity between the sexes (parallelism test: p = 0.114; coincidence test: p = 0.093). From 2000 to 2021, there was a disparity in proportional mortality from stroke between the sexes of the population in the metropolitan area of Greater Vitoria, Brazil. However, the time series of mortality rates between the sexes did not reveal any disparity in the study period.

Epidemiological profile and spatial analysis of probable cases of dengue registered from 2010 to 2021 in the state of Maranhão

Dengue is a disease of viral etiology transmitted by mosquitoes, with a high incidence in tropical countries. Dengue has great epidemiological importance in the Americas and in Brazil. The goal of this study was to analyze the spatial distribution and to describe the epidemiological profile of probable cases of dengue in the State of Maranhão from 2010 to 2021. Statistical analysis through non-parametric tests and spatial analysis were performed using the Moran’s Global Index and Local Indicators of Spatial Association (LISA) and Space-time Scan statistic. Data were collected from the Department of Informatics of the Unified Health System in Brazil (DATASUS) between 2010 and 2021. The highest number of probable cases occurred in 2016 (23,938) and they were concentrated in the first half of each year. The female gender had the highest proportion of cases (54.9%). The cases predominated in the group of people aged between 20 and 39 years old (35.5%). People with incomplete elementary school degree were the most affected (43.0%). The brown race had more registered cases (80.7%). The municipality that had the highest incidence was Barra do Corda (7,418.5 per 100.000 inhabitants in 2016). In the local spatial analysis, 55.8% of the clusters of municipalities High- High occurred in the South region from the State of Maranhão. The municipality of Barra do Corda presented the highest relative risk (55.91) in the Space-time Scan statistic. People of the brown race, with incomplete schooling and young adults were the most affected by the dengue disease. The South region of the State showed greater epidemiological importance because it has representative clusters High-High. KEY WORDS: Dengue; incidence; spatial analysis; State of Maranhao.

Regulation of elective surgeries in the Unified Health System: a bibliometric analysis of waiting list management in Brazil

This study aims to analyze the bibliometric profile regarding the regulation of elective surgeries in the Unified Health System in Brazil from 2011 to 2021. Bibliometric analysis study that selected and evaluated scientific articles with full texts, in Portuguese, available free of charge in electronic format , through the keywords: Elective surgical procedures, Waiting lists and Unified Health System, published between January 2011 and April 2021, in the VHL, Web of Science and Scopus databases. Programs were used for the selection/export and construction of the portfolio, such as Rayyan Software, JabRef®, Microsoft Excel® software and VOSViewer® Software for image creation. To generate the InOrdinatio index value, CiteScore 2021 and Google Scholar were used. The most relevant articles, authors and journals that published the most on the topic were statistically described. This study can contribute to planning improvements to the current regulatory system, by evaluating the potentialities and weaknesses of this System and creating new management tools, in order to solve currently existing problems.

Jóvenes investigadores: enfrentamiento a las arbovirosis y participación juvenil en el território

This study analyzes a Scientific Initiation (SI) program on arboviroses, from the perception of young high school students in Ceilândia – Distrito Federal. Objective: It aims to understand to what extent the SI mobilizes these young people to participate in surveillance and health promotion actions in the territory and understand their motivation to participate in this project. Methodology: The methodology included the analysis of the essays written for the selection to the Training Course for Scientific Initiation in Basic Education and the Arboviroses, the administration of this course, and later a focus group with students to analyze the SI educational process they experienced. Results: The result of the Content Analysis showed that the students’ perception about the SI could be grouped into six categories: students’ motivation for the scientific initiation; the learning process; the training of young scientists; health and environment; youth participation and empowerment, and perceptions of the Public health system in Brazil (SUS). Conclusion: Confronting arboviroses requires broad-spectrum policies and interventions, and the SI strengthened these young students as subjects of rights, broadened their perception of science, health, relationship with the environment, with the Sistema Único de Saúde and stimulated interest in preventive actions to combat arboviroses in these territories. Submission: 12/19/23| Review: 03/27/24| Approval: 04/24/24

Cost-Utility of Venoarterial Extracorporeal Membrane Oxygenation in Refractory Cardiogenic Shock: A Brazilian Perspective Study.

Refractory cardiogenic shock (CS) is associated with high mortality rates, and the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a therapeutic option has generated discussions. Therefore, its cost-effectiveness, especially in low- and middle-income countries like Brazil, remains uncertain.Objectives: To conduct a cost-utility analysis from the Brazilian Unified Health System perspective to assess the cost-effectiveness of VA-ECMO combined with standard care compared to standard care alone in adult refractory CS patients. We followed a cohort of refractory CS patients treated with VA-ECMO in tertiary care centers located in Southern Brazilian. We collected data on hospital outcomes and costs. We conducted a systematic review to supplement our data and utilized a Markov model to estimate incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) and per life-year gained. In the base-case analysis, VA-ECMO yielded an ICER of Int$ 37,491 per QALY. Sensitivity analyses identified hospitalization cost, relative risk of survival, and VA-ECMO group survival as key drivers of results. Probabilistic sensitivity analysis favored VA-ECMO, with a 78% probability of cost-effectiveness at the recommended willingness-to-pay threshold. Our study suggests that, within the Brazilian Health System framework, VA-ECMO may be a cost-effective therapy for refractory CS. However, limited efficacy data and recent trials questioning its benefit in specific patient subsets highlight the need for further research. Rigorous clinical trials, encompassing diverse patient profiles, are essential to confirm cost-effectiveness and ensure equitable access to advanced medical interventions within healthcare systems, particularly in socio-economically diverse countries like Brazil.

Congenital syphilis, syphilis in pregnancy and prenatal care in Brazil: An ecological study.

The aim of this research was to evaluate the incidence of congenital syphilis and the ratio between congenital syphilis and syphilis in pregnant women in Brazil according to socioeconomic indicators (inadequate water supply and sanitation; illiteracy at 15 years of age or older; household income per capita; proportion of poor people; Gini index; human development index; and average health expenditure per inhabitant by the health system) and prenatal quality-of-care indicators. We conducted an ecological study using a sample composed of 257 municipalities, each with ≥ 100,000 inhabitants. Data was collected from four public databases: the Brazilian Institute of Geography and Statistics, comprising socioeconomical data from the 2010 census; and the data of 2019 available in the databases of the Department of Informatics of the Brazilian Health System, Information and Management of Primary Care, and the Electronic Citizen Information System. Descriptive analysis of dependent and independent variables and bivariate analysis by Negative Binomial regression were carried out. The mean incidence of congenital syphilis was 38% higher in municipalities with a Human Development Index up to 0.785 (ratio of means [RM] = 1.38; p = 0.049) and 57% higher among populations where less than 50% of primary healthcare services provided a rapid test for syphilis (RM = 1.57; p < 0.001). The ratio between congenital syphilis and syphilis in pregnant women was 29% higher in municipalities with a low household income per capita (RM = 1.29; p < 0.001) and 28% higher in locations where less than 50% of the primary healthcare services provided a rapid test for syphilis (RM = 1.28; p < 0.001). There was no statistical significance of the quality of prenatal care compared to the outcomes. This result underscores the challenges in detecting syphilis infections among pregnant women during prenatal care, consequently increasing the risk of vertical transmission of the disease to the fetus. Traits of inequality in the occurrence of congenital syphilis also draw attention to strategies to reduce health inequities and improve prenatal care.