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In all countries of the world, increasing pressures on scarce resources have meant that all investments, inside and outside the health sector, have come under closer scrutiny. This in turn has led to an increased interest in analytical approaches to the evaluation of alternative strategies from an economic prospective. Traditionally, 3 issues have been adressed in the evaluation of health care or pharmaceutical agents: 1.The first deals with safety; is it harmful to people? Toxicology, clinical and post-marketing surveillance studies are used to address this question. 2. The second deals with efficacy: can a particular therapeutical intervention work? For an example, under ideal conditions when a patient is given the correct dose, at the correct time, over an appropriate period, does a therapeutic intervention have the desired effect? 3. The third set deals with effectiveness: does the intervention (drug) work in the real world when patients use it on a day-today basis according to their own perception of instructions given to them by their physicians? To these traditional analyses economists and health economists have recently added a new area of evaluation, the question of efficiency. The essence of this new perspective is expressed in the question "Are we getting the best outcome for the money we are spending? Economic assessment is about choosing between alternative uses of resourses. In doing so, both of the costs and the outcomes of investments are considered. As the basic assumption of any analysis is that there are not, and never will be, enough resourses to satisfy all needs completely trade offs have to be made where to invest and where not to. Economic analysis can be conceived in 3 dimensions. Each dimension describes an important aspect of the analysis: 1.The design of the analysis may be of 4 types: cost-minimization, cost-benefit, cost-effectiveness or cost-utility; if all consequences are essentially identical between the drug and relevant comparators, a cost-minimization analysis is adequate; In other instances one of the other three economic analysis is required. In cost-utility analysis the quantity of life improvement (mortality) and the health related quality of life improvement ~re combined into a single metric (QALYs). This combination has the advantage of permitting broad comparisons between the performed analysis and other interventions the health care sector. In costbenefit analysis the health improvement is translated into an equivalent monetary value. Two approaches can be used to value the health improvement: a. Human capital, and; b. Contingent valuation using willingness to pay. 2. Different points of view may be taken in the analysis, those of society, the prayer, the provider, or the patient; All studies should report from a comprehensive societal perspective. Also, the perspective should be broken down into those of other relevant viewpoints, including that of the p~imary decision maker. 3. Different types of costs and benefits may be included: direct, indirect and intangible. Resourses used in each intervention being compared should be described first in natural (nonmonetary) units. When possible standard cost values should be used in costing out resourse utilization. Whenever possible, indirect costs should be documented and reported. Costs items are included or excluded from the analysis depending on the viewpoint adopted. Finnaly, with the growing international literature in economic evaluation and the rapid international apread of health technologic, there is a need to undertake, or at least, interpret economic evaluations on the internationalleveI. Health care decision makers, especially in those countries having limited resourses for health technology assessment (the case in most, if not all developing countries) may wish to reinterpret in their own setting the results of an economic evaluation that was done elsewhere. However, a number of factors limit the generalizability of economic data and extrapolation of results is an issue not only between but also within countries. Among the factors that are likely to differ from place to place, it can be cited: 1. Demography and Epydemiology of Disease. 2. Health Care Resourses Distribution and Availability. 3. Variation in Clinical Pratice. 4. Incentives to professionals and institutions. 5. Relative Price Levels. The few cross-national economic studies undertaken to date indicate that differences in these factors do impact the ecomomic evaluation of health technologies. As a result, whenever possible, both economic and clinical data should be gathered in each country. In conclusion, the ultimate aim of economic evaluation is to assist decision making and not to replace decision making.

To compare the efficacy of the combination therapy Methotrexate (MTX) and Chloroquine (CHLO) with MTX and Placebo (PLA) in the treatment of Rheumatoid Arthritis. A total of 82 patients with Rheumatoid Arthritis (RA), diagnosed according to the American College of Rheumatology criteria, received orally either MTX 7.5 mg/week and CHLO 250 mg/day or MTX 7.5 mg/week and PLA 1 tablet/day. Adverse effects (AE) were monitored monthly and disease activity was assessed at 0, 2, 4 and 6 months. Sixty-eight patients completed the study. All outcome measures improved significantly in both treatment groups. Patients receiving MTX/CHLO ended the study with a significantly lower joint count, greater grip strength and better functional ability the patients in the MTX/PLA group, respectively; 4.5 vs 7.5 (P < 0.05), 113.3 vs 89.1 (P < 0.05) and 0.636 vs 0.811 (P < 0.05). Mild AE were more frequently observed in the MTX/CHLO, 17 events in 15 patients, compared to 9 events in 8 patients in the MTX/PLA group (NS). These data indicate that MTX/CHLO is slightly more efficacious and toxic than is MTX/PLA in the treatment of RA.

Forty-four patients with active Rheumatoid Arthritis were entered into a 6-month double-blind trial comparing homeopathy and placebo. The treatments were generally equally effective in most assessments. Statistically significant improvements were produced, however, in 3 of 5 and 2 of 5 results respectively assessed in homeopathic and placebo treated groups. There was no statistically significant difference between groups. Adverse effects were scarcely and comparably reported in both groups and did not require a change in therapy.

H ealthcare systems in many developing countries face a major challenge: how to meet the demand for 21st century standards of health care and technology with funds that, as a percentage of gross domestic product (GDP), remain lower than what developed nations were investing in health in the 1980s. And, furthermore, how can developing countries meet such expectations when they are still dealing with health problems that rich countries had overcome 40 or 50 years ago? Take my country, for example. In recent years Brazil has been spending some 7-8% of its GDP (both public and private sector investment) on the health sector. Over the past few decades developed nations have been progressively increasing their spending on health. In the 1960s countries such as Canada, France, Switzerland, Australia, Italy, and the United States spent some 4-5% of their GDP on health. By the end of the 1980s this figure had …

(1993). Use of Unconventional Remedies for Arthritis in Brazil. Scandinavian Journal of Rheumatology: Vol. 22, No. 4, pp. 203-204.

Objective The present study aimed to determine indirect costs of rheumatoid arthritis (RA) in a sample of patients followed at a public health-care facility in Brazil. Factors potentially associated with higher indirect costs in these patients were also investigated. Methods This cross-sectional study included patients between 18 and 65 years old with RA according to the American College of Rheumatology criteria. Patients who were working, on sick leave or retired early due to RA were invited to participate in the survey. A systematic structured interview was conducted in all patients including demographic, socioeconomic, and clinical variables and an experienced rheumatologist examined all patients. Estimates of the indirect costs in the preceding 12 months were performed using the human-capital approach based on the society perspective. Multiple linear regression models were used to determine the variables associated with higher indirect costs. Results A total of 192 patients were included in the study. Forty-seven of them (24.5%) had retired early due to RA, 62 others (32.3%) were on sick leave due to RA while 83 patients (43.2%) were working at the time of the interview. Estimated indirect cost for this population was US$ 466,107.81 or US$ 2,423.51 per patient per year. Factors associated with higher costs were RA poor functional class, high socioeconomic status and male patients (p Conclusions Estimated costs found in our population are similar to that described in more developed countries. Indirect costs were higher in patients with poor functional classes, high socioeconomic status, and men.

ObjectivesThe routine screening for macroprolactin of all hyperprolactinemic patients may avoid unnecessary imaging procedures and medication prescription. The study described the frequency and types of tests requested after a diagnosis of high serum prolactin concentration, and assessed whether the diagnosis of macroprolactinemia resulted in lower downstream utilization and costs compared with hyperprolactinemic patients.MethodsA cost analysis was conducted using a decision tree to model the health-care utilization of the two groups. The database of the Fleury Medicina e Saúde provided the tests and medication of patients with a prolactin value ≥30 µg/L for a period of 6 months.ResultsSix hundred fifty-four of 1793 patients (36.5%) had hyperprolactinemia because of macroprolactin. The average number of tests per individual was higher (P = 0.001) in the patients with true hyperprolactinemia (3.07) than in patients with macroprolactinemia (2.51). The average cost in the hyperprolactinemic group (R$425 or €162) was significantly higher (P < 0.001) than the macroprolactinemic group (R$340 or €130), an incremental cost 25% higher.ConclusionThe macroprolactin screening did not completely avoid inappropriate clinical investigation or associated health-care costs. Our results demonstrate the importance of proper medical education and knowledge diffusion of the meaning of macroprolactinemia.

ObjectivesTo find preferences for treatment expressed by lupus patients and physicians (who were asked to assume they have lupus) and to explore if certain variables explain these preferences.MethodsOne hundred seventy-two patients and 202 physicians were interviewed using a lupus nephritis decision board that describes the treatment options and their potential benefits and risks. Clinical and sociodemographic variables were collected. Participants were asked to indicate their preferred treatment and provide justification for their choice. Descriptive statistics, t tests, and Pearson's chi-square tests were used to determine the significance of differences in the decisions made by the two groups. A logistic regression model determined which factors contributed to treatment decisions.ResultsThe average age of study participants was 34 ± 8 years for patients and 31 ± 7 years for physicians. Sixty-eight percent of patients and 96% of physicians (P < 0.001) selected the oral option. Patients and physicians justified their choice of treatment using different arguments (P < 0.001 in each case). Logistic regression showed that risk potential (P < 0.001) and a history of joint involvement (P = 0.011) were the arguments used most often to explain a patient's decision and the risk of side effects was most relevant among physicians (P < 0.001).ConclusionsUsing a decision board, patients and physicians were found to have different preferences for treatment when faced with the same treatment options. Further, the variables that influence their preferences are different.

Wyeth Consumer Healthcare Background: Adequate nutrition plays an important role in bone mass accrual and maintenance and has been demonstrated as a significant tool for the prevention of fractures in individuals with osteoporosis.Objective: the aim of the present study was to evaluate bone health-related nutrients intake and its association with osteoporotic fractures in a representative sample of 2344 individuals aged 40 years or older in Brazil.Methods: in a transversal population-based study, a total of 2420 individuals over 40 years old were evaluated from March to April 2006. Participants were men and women from all socioeconomic classes and education levels living around the Brazilian territory Individuals responded a questionnaire including self reported fractures as well a 24-hour food recall. Nutrient intakes were evaluated by Nutrition Data System for Research software (NDSR, University of Minnesota, 2007). Low trauma fracture was defined as that resulting of a fall from standing height or less. Nutrient intakes adequacies were performed by using the DRI's proposed values. Statistical analysis comprises Oneway ANCOVA adjusted by age and use of nutritional supplements and multiple logistic regression. SAS software was used for statistical analysis.Results: Fractures was reported by 13% of men and 15% of women. Women with fractures presented significantly higher calcium, phosphorus and magnesium intakes. However, in all regions and socio-economical levels mean intakes of bone related nutrients were below the recommended levels. It was demonstrated that for every 100 mg/phosphorus increase the risk of fractures by 9% (OR 1.09; IC95% 1.05-1.13, p < 0.001).Conclusion: the results demonstrated inadequacies in bone related nutrients in our population as well that an increase in phosphorus intake is related to bone fractures. Universidade Federal de São Paulo EPM, Div Rheumatol, São Paulo, Brazil Univ São Paulo, Fac Saude Publ, Dept Nutr, São Paulo, Brazil Universidade Federal de São Paulo EPM, São Paulo Hlth Care Econ Ctr, São Paulo, Brazil Universidade Federal de São Paulo EPM, Div Rheumatol, São Paulo, Brazil Universidade Federal de São Paulo EPM, São Paulo Hlth Care Econ Ctr, São Paulo, Brazil Web of Science

O objetivo deste estudo foi adaptar e validar o Foot Health Status Questionnaire (FHSQ) avaliando suas propriedades de medida. Este instrumento foi traduzido, traduzido de volta para o inglês, avaliado por comitê multidisciplinar e submetido a pré-teste, gerando o FHSQ-Br. O FHSQ-Br foi submetido a teste de campo em um grupo de estudo composto por 65 pacientes com Artrite Reumatóide (AR) para avaliar a confiabilidade teste-reteste, a consistência interna e a validade do construto. A validade do construto foi testada correlacionando os escores do instrumento com dados clínicos e laboratoriais usados para avaliar a AR. Este estudo demonstrou que o FHSQ-Br é um instrumento confiável, consistente e válido, útil na avaliação da saúde dos pés, sendo passível de adaptação para diferentes culturas The purpose of this study was to conduct a cross-cultural adaptation and validation of the Foot Health Status Questionnaire (FHSQ) evaluating its measurement properties. All ten domains of the FHSQ were translated into Portuguese by two Brazilian translators creating Version 1. This version was back-translated by two native English-speaking teachers who made suggestions for Version 1, creating Version 2. A multidisciplinary committee was formed to test the instrument’s semantic, idiomatic, experiential and conceptual equivalences. After being reformulated and approved by the committee, Version 3 was pre-tested on a group of patients from the Rheumatology Service of the Hospital das Clínicas. They answered this version and made suggestions for the better understanding of the instructions, questions and response option. The FHSQ-Br was then created. The translated and adapted version was submitted to field test on a study group composed of sixty-five Rheumatoid Arthritis (RA) patients to evaluate test-retest reliability, internal consistency and construct validity. The construct validity of the FHSQ-Br was tested correlating the scores to clinical and laboratory parameters commonly used to assess RA (Health Assessment Questionnaire; Numbered Rating Scale for foot pain; foot X-rays; erythrocyte sedimentation rate and C-reactive protein). The cultural adaptation of the FHSQ was successfully accomplished, since patients suggested changes in only three items of the instrument during the pre-test phase. In the field test, the intra-class correlation coefficients showed high reliability for both intra- and inter-observer correlations. Internal consistency coefficients were statistically significant (p

A osteoporose é um importante problema de saúde pública. Caracteriza-se pela baixa densidade mineral óssea associado a fraturas de fragilidade. Geralmente, as fraturas acometem o quadril, vértebras, ossos dos ombros e punhos. A doença é típica de idades avançadas e ocorre principalmente em mulheres na pós-menopausa, devido à baixa condição hormonal. Com o objetivo de auxiliar na discussão a respeito da qualidade do uso dos medicamentos, realizou-se uma avaliação econômica das estratégias terapêuticas para o tratamento da osteoporose na pós-menopausa. Para compor esta avaliação, foram realizados cinco estudos. O primeiro estudo destaca a dimensão dos gastos com medicamentos para as doenças osteometabólicas no Brasil, no âmbito do Sistema Único de Saúde. O segundo é uma revisão das avaliações econômicas realizadas no Brasil e no mundo enfocando o tema. O terceiro trata dos gastos com medicamentos para o tratamento da osteoporose na pós-menopausa. O quarto estudo descreve os custos de fraturas de baixa energia, decorrentes de queda de própria altura, típicas da osteoporose. O último estudo engloba uma avaliação econômica completa, de custo-efetividade dos medicamentos destinados ao tratamento da osteoporose na pós-menopausa. No primeiro estudo, foram identificados 611.419 indivíduos que utilizaram o Programa de Medicamentos Excepcionais no período de 2000-2004, sendo que as doenças do sistema osteomuscular e do tecido conjuntivo representaram 21,7% de todos os diagnósticos do programa. O custo médio dos medicamentos que afetam a estrutura óssea e a mineralização foi de R$26,50±60,56. Foram encontrados 30 estudos na revisão sistemática das avaliações econômicas dos medicamentos para o tratamento da osteoporose na pós menopausa. Somente dois estudos brasileiros. Observou-se que, no geral, os bisfosfonatos foram as estratégias mais avaliadas e que resultaram em melhores relações custo-efetividade incrementais. No estudo de gastos com medicamentos excepcionais destinados ao tratamento da osteoporose foram identificadas 72.265 mulheres que receberam medicamentos no período de 2000-2006. A população era composta predominantemente por mulheres com idade entre 60-69 anos, que iniciaram o tratamento em 2000 e sofreram fraturas osteoporóticas prévias, sendo o alendronato de sódio o medicamento mais utilizado no início do tratamento. Tendo como padrão de referência o alendronato de sódio, os medicamentos raloxifeno e calcitonina sintética foram as alternativas com maior impacto sobre o gasto médio mensal com medicamentos. O quarto estudo, que descreveu os custos das fraturas no Sistema Único de Saúde, encontrou que os maiores custos foram para as fraturas vertebrais, seguido das fraturas dos quadris, ombros e punhos. Custos de fraturas vertebrais variaram de R$18.299,31 a R$36.970,99; das fraturas de quadris de R$3.870,07 a R$20.042,60. Os custos para as fraturas de ombros variaram de R$2.467,26 a R$8.074,55. Custos das fraturas de punhos variaram de R$827,64 a R$7.043,29. O maior percentual do custo, na maioria das vezes, estava relacionado às próteses. Os resultados do último artigo, de custo-efetividade dos medicamentos para a osteoporose na pós-menopausa indicaram que para pacientes com osteoporose com e sem fraturas prévias, iniciar o tratamento na faixa etária de 40-49 e 50-59 anos, o alendronato mostrou-se mais custo-efetivo; de 60-69 anos, além do alendronato, a estratégia de não tratar e o denosumabe. Na faixa etária de 70-79 e 80 ou mais, somente o alendronato foi custo-efetivo. A tese como um todo identificou os principais aspectos relacionados à avaliação econômica no que tange aos gastos com medicamentos e os custos das fraturas relacionadas à osteoporose. A avaliação econômica identificou as opções terapêuticas que apresentaram uma boa razão de custo efetividade incremental, ou seja, o custo adicional gasto para cada ano de vida adicional ganho com o uso da medicação, dentro do limiar de custo-efetividade aceito no país, que é de um a três vezes o Produto Interno Bruto. Osteoporosis is a relevant public health problem. It is characterized by low bone mineral density associated with fragility fractures. Generally, fractures involve the hip, vertebrae, forearm and wrist. The disease occurs frequently in aging people and primarily in postmenopausal women, due to the low hormone levels. In order to assist the discussion about the quality use of medicines in the treatment of postmenopausal osteoporosis, we conducted an economic evaluation of the available therapeutic strategies. To compose this major project, we conducted five separate studies. The first study highlights the amount spent by the National Health System on drugs for the treatment of bone metabolic diseases in Brazil. The second one is a review of economic evaluations conducted in Brazil and in other countries, focusing on the theme. The third regards the costs of the drugs used in the treatment of postmenopausal osteoporosis. The fourth study describes the costs of low-energy fractures resulting from simple falls, typical of the osteoporosis. The latter study includes a full cost-effectiveness economic evaluation, of drugs for the treatment of postmenopausal osteoporosis. We identified 611,419 individuals registered in the Exceptional Drug Program in 2000-2004. Musculoskeletal system and connective tissue diseases represented 21.7% of all illnesses included in this Program. The average cost of drugs affecting bone structure and mineralization was R$26.50±60.56. The systematic review of economic evaluations of medicines used in the treatment of osteoporosis in postmenopausal women showed that in general, bisphosphonates have been most often evaluated and were considered the best strategies resulting in the best incremental cost-effectiveness. In the study of the expenditures of the Exceptional Drug Program on the treatment of osteoporosis we identified 72,265 women who received medication during the period 2000-2006. The population consisted predominantly of women aged 60-69 years, who started treatment in 2000 and suffered previous osteoporotic fractures. Alendronate sodium is the most commonly drug used in early treatment. Considering alendronate sodium as reference, the drugs raloxifene and calcitonin were alternatives with greater impact on the increasing average monthly expenses of medicines. The fourth study was a cost analysis of fractures under the perspective of the National Health System. It showed that costs were higher for vertebral fractures, followed by fractures of the hips, forearm and wrists. Costs of vertebral fractures ranged from R$ R$18,299.31 a R$36,970.99; hip fractures from R$3,870.07 a R$20,042.60. Costs for forearm fractures ranged from R$2,467.26 a R$8,074.55. And costs of fractures wrists ranged from R$827.64 a R$7,043.29. Mostly the higher cost of the treatment was due to the purchase of prostheses. The results of the last article on cost-effectiveness of drugs for osteoporosis in postmenopausal women showed that for patients with osteoporosis, initiating treatment in the age of 40-49 and 50 -59 years with alendronate was the cost-effective. To women aged 60-69 years, in addition the alendronate, denosumab and not treat were cost-effective. On women aged 70-79 and 80 or more, alendronate again was the cost-effective option. In this thesis, as a whole, we identified the main aspects of economic evaluation regarding drug expenditures and costs of osteoporosis-related fractures. The economic evaluation identified the therapeutic options that had a good incremental cost effectiveness ratio, i.e., the additional cost spent for each year of additional life gained with the use of medication within the acceptable willingness to pay threshold of the country, which is one to three times the Gross Domestic Product.

Esta tese representa o aprofundamento do estudo das estimativas de custos, componente integrante e determinante das avaliações econômicas, enquanto parte do projeto de pesquisa Estudos de custo-efetividade da incorporação de novas vacinas à rotina do Programa Nacional de Imunizações: Rotavírus, Varicela, Pneumocócica conjugada, Meningocócica C conjugada e Hepatite A desenvolvido por solicitação do Programa Nacional de Imunização/PNI da Secretaria de Vigilância em Saúde/SVS do Ministério da Saúde, a partir de 2005. A tese teve como objetivo analisar as condições de uso, dificuldades e repercussões de diferentes métodos de estimativas de custos em estudos de custo-efetividade de vacinas de duas tecnologias específicas, vacinas contra rotavírus e varicela, assim como a relação entre as estimativas de custos e os resultados. As estimativas de custos estão condicionadas pelas características gerais da doença sob análise (aguda no caso de rotavírus e com seqüela no caso de varicela), assim como por questões metodológicas gerais (escolha teórico-conceitual, métodos e fontes de dados) e especificidades do caso brasileiro. Para esta tese, houve maior detalhamento das estimativas de custos diretos no cuidado da doença, com a inclusão de custos específicos do sistema de saúde suplementar para as duas doenças, inclusão de participação pública na dispensação de medicamentos no caso de rotavírus e inclusão de custos de medicamentos do sistema público de saúde no caso de varicela. Como resultado, houve aumento do custo total da doença estimado de 16% para rotavírus e 11% para varicela, assim como aumento de economia (custo total da doença evitado) de 18% e 16%, respectivamente, com a introdução de cada vacina. Apesar do maior detalhamento das estimativas de custos ter reduzido a razão de custo-efetividade incremental em 20% para rotavírus e 4% para varicela, o nível de custo-efetividade dos dois programas de vacinação não foi alterado. Os resultados das avaliações econômicas de vacinação contra rotavírus e varicela mostraram-se mais sensíveis às estimativas de custos do programa de vacinação, em especial o preço da vacina, apontando a relevância do custo da tecnologia sob análise para incorporação em comparação aos demais custos This thesis represents a deeper study of the cost estimates, an integrant and determinative component of economic evaluations, as part of the project Costeffectiveness studies of the incorporation of new vaccines into the routine of the National Immunisation Program: Rotavirus, Varicella, Pneumococcal conjugate, Meningococcal C conjugate and Hepatitis A. The project has been developed on the request of the National Immunisation Program/PNI of the Secretary of Sanitary Surveillance/SVS of the Ministry of Health since 2005. The objective of the thesis was to analyse the conditions of use, difficulties and repercussions of different cost estimates methods in the cost-effectiveness studies of two specific technologies, vaccines against rotavirus and varicella, as well as the relationship between the cost estimates and the results. The cost estimates are conditioned by general characteristics of the disease under analysis (acute in the case of rotavirus and with long-term disability in the case of varicella), general methodological issues (theoretical choice, methods and sources of data) and specificities to the Brazilian case. This thesis brings a more detailed estimation of direct medical costs, with the inclusion of specific costs of the private health care system for the two diseases, inclusion of public participation for dispensing drugs in the case of rotavirus and inclusion of drugs costs in the public health care system in the case of varicella. As a result, there was an estimated disease total cost increase of 16% for rotavirus and 11% for varicella, as well as increase of savings (disease total cost avoided) of 18% and 16%, respectively, with the introduction of each vaccine. Although the more detailed cost estimates have reduced the incremental cost-effectiveness ratio by 20% for rotavirus and 4% for varicella, the cost-effectiveness level of the two vaccination programs was not altered. The results of the economic evaluations of vaccination against rotavirus and varicella were more sensitive to the vaccination program cost estimates, especially the vaccine price, pointing out the relevance of the cost of the technology under analysis for incorporation comparatively to the other costs

INTRODUÇÃO: A escolha entre diferentes modelos de análise de decisão introduz variabilidade nos resultados das avaliações econômicas. Modelos estáticos não captam os efeitos indiretos da vacinação comprometendo a avaliação geral dos benefícios da vacinação. Neste trabalho foram desenvolvidos um modelo dinâmico e um modelo estático para a análise de custo-efetividade (ACE) da vacina contra varicela e foram comparados os resultados obtidos com os dois modelos. MÉTODOS: Avaliação econômica completa do tipo ACE usando modelagem. As análises compararam duas estratégias: 1) introdução da vacinação infantil de rotina aos 12 meses de vida; versus 2) situação existente (vacinação após os surtos em creches e vacinação de imunodeprimidos). As análises foram conduzidas no horizonte temporal de 30 anos. RESULTADOS: O modelo dinâmico estimou que na ausência do programa de vacinação ocorreriam 2 915 294 casos de varicela por ano no Brasil, resultando em 879 095 casos ambulatoriais, 4 507 hospitalizações, 119 mortes e 4 casos de sequela. O custo total anual da varicela foi estimado em R$27 378 957 para a sociedade e em R$14 412 610 para o sistema de saúde. A razão de custo-efetividade incremental (RCEI) por ano de vida salvo foi R$14 749 na perspectiva da sociedade e R$16 582 na perspectiva do sistema de saúde. O modelo estático estimou que na ausência do programa de vacinação ocorreriam 1 656 547 casos de varicela por ano no Brasil, resultando em 629 488 casos ambulatoriais, 5 120 hospitalizações, 82 mortes e 1 caso de sequela. O custo total anual da varicela foi estimado em R$17 311 412 para a sociedade e em R$9 570 551 para o sistema de saúde. A RCEI por ano de vida salvo foi R$35 254 na perspectiva da sociedade e R$36 599 na perspectiva do sistema de saúde. Aplicando o limiar de custoefetividade da Organização Mundial de Saúde (OMS) aos resultados obtidos com o modelo dinâmico a vacinação foi considerada uma estratégia custo-efetiva o mesmo não aconteceu com os resultados do modelo estático. Na análise de sensibilidade da taxa de incidência utilizada no modelo estático a RCEI por ano de vida salvo foi R$19 905 na perspectiva da sociedade e R$21 176 na perspectiva do sistema de saúde e a vacinação foi considerada custo-efetiva. CONCLUSÃO: A estimativa de custo-efetividade de programas de vacinação exige o uso de um modelo apropriado. O que é julgado como apropriado será influenciado pelo contexto da avaliação proposta, conhecimento da epidemiologia da doença, disponibilidade de dados e existência de uma equipe qualificada para construir e interpretar os resultados desses modelos. BACKGROUND: The choice between different decision analysis models introduces variability in the results of economic evaluations. Static models do not take into account the indirect effects of vaccination, thus compromising the overall assessment of vaccination benefits. This work developed two models one dynamic and another static to conduct cost-effectiveness analyses (CEA) of varicella vaccine, comparing the results of the two. METHODS: Comprehensive economic evaluation CEA using modeling. The analysis compared two strategies: 1) introduction of routine vaccination for children under 12 months, versus 2) current situation (vaccination after outbreaks in nurseries and vaccination of immunocompromised). The time horizon of the analysis was 30 years. RESULTS: The dynamic model estimated that in the absence of the vaccination program, 2 915 294 cases of varicella occurred every year in Brazil, resulting in 879,095 outpatient cases, 4,507 hospitalizations, 119 deaths and 4 sequela cases. The total annual cost of varicella was estimated at R$ 27,378,957 for the society and at R$ 14,412,610 for the health care system. From the perspective of society, the incremental cost-effectiveness ratio (ICER) was R$ 14,749 per life-year saved, while from the perspective of the health care system, it amounted to R$ 16,582. The model estimated that, in the absence of a vaccination program, there would be 1,656,547 cases of varicella every year in Brazil, resulting in 629,488 outpatient cases, 5,120 hospitalizations, 82 deaths and 1 case of sequela. The total annual cost of varicella was estimated at R$ 17,311,412 for the society, and at R$ 9,570,551 for the health care system. The ICER was R$ 35,254 and R$ 36,599 from the perspective of society and the health care system, respectively. When applying the World Health Organization (WHO)\'s cost-effectiveness threshold to the dynamic model results, vaccination was considered a cost-effective strategy; this was nevertheless not the case with the static model. In the sensitivity analysis for the incidence rate employed in the static model, the ICER was R$ 19,905 per life-year saved from the perspective of society, and R$ 21,176 from the perspective of the health care system, with vaccination deemed cost-effective. CONCLUSION: Estimating the cost-effectiveness of vaccination programs requires the use of an appropriate model. Establishing an appropriate course of action will depend on the context of proposal evaluation, understanding of disease epidemiology, availability of data, and the existence of a qualified team to build these models and interpret their results.

A hepatite pelo VHC é uma das mais freqüentes causas de doença hepática, sendo a prevalência mundial estimada de 1% a 5%, com aproximadamente 180 milhões de pessoas infectadas. Atualmente, é sabido que problemas emocionais e a própria avaliação da condição de saúde podem estar alterados em pacientes com hepatite pelo VHC assim como ocorre em outras doenças. Objetivos: Este estudo tem como objetivo principal a avaliação da Qualidade de Vida Relacionada à Saúde (QVRS) numa população de candidatos a doadores de sangue, portadores do VHC. Métodos: Foram estudados 120 pacientes, recém- diagnosticados quanto a sua condição de portador do VHC, 63% homens, idade média de 38,6 (11,0). Os pacientes foram divididos em três grupos de acordo com a gravidade da doença: Grupo A, n = 37. Pacientes sem indicação de biópsia hepática, Grupo B, n = 83. Pacientes com indicação de biópsia hepática. B.1 sem indicação de tratamento antiviral, ou seja, alteração arquitetural do fígado < 2 e/ou atividade periportal ≤ 2 n = 40. B.2 com indicação de tratamento antiviral, alteração arquitetural do fígado ≥ 2 e/ou atividade periportal > 2 n = 43. O grupo controle foi constituído por 120 doadores de sangue, negativos para o antiVHC, pareados por sexo e idade. As seguintes comparações foram realizadas: a) comparação entre os pacientes portadores de VHC e o grupo controle b) comparação entre os três grupos de pacientes com os diferentes estadiamentos da doença c) avaliação de alterações ao longo do tempo e em função do tratamento d) comparações entre gêneros e) estudo das co-morbidades, álcool e drogas. No grupo B.2, no sexto mês de tratamento, foram comparados os pacientes que permaneceram com RNA-VHC positivo versus os com negativação do RNA-VHC. Para avaliação de qualidade de vida utilizamos dois questionários, o SF 36, instrumento genérico, e o LDQOL questionário híbrido, genérico e específico, sendo as questões genéricas compostas pelo SF 36 e mais 75 questões específicas para doenças hepáticas. O SF 36 foi utilizado na comparação dos pacientes com VHC e o grupo controle e o LDQOL em todos os pacientes. Resultados: Nas comparações entre os pacientes com VHC e os controles pareados, foram encontradas diferenças estatisticamente significantes, onde, os pacientes apresentaram pontuações menores que as do grupo controle. Houve aumento do número de domínios alterados com a progressão da doença: cinco, sete e oito domínios, respectivamente, para os grupos A, B.1 e B.2. Na comparação dos pacientes em relação à gravidade da doença, não foi encontrada diferença estatisticamente significante nas questões genéricas. No entanto, em relação às questões específicas, foram encontradas diferenças estatisticamente significantes nas dimensões, Sintomas da Doença Hepática (p = 0,041), Concentração (p = 0,035) e Estigma da Doença Hepática (p = 0,024). Nas comparações longitudinais, os pacientes sem indicação de biópsia e os biopsiados sem indicação de tratamento antiviral apresentaram alterações em relação ao domínio específico do LDQOL, Estigma da Doença Hepática, onde, no sexto mês de acompanhamento, houve diminuição da qualidade de vida nesse aspecto. Em relação ao domínio específico do LDQOL, Preocupações com a Doença, o grupo biopsiado sem indicação de tratamento antiviral mostrou melhora no sexto mês de acompanhamento. O grupo em tratamento antiviral apresentou alterações durante o tratamento, com diminuição da qualidade de vida em relação às questões genéricas e específicas do LDQOL. Nesse mesmo grupo, ao final do sexto mês, os pacientes em tratamento com negativação do RNA-VHC apresentaram melhor qualidade de vida quando comparados aos que permaneceram com o RNA-VHC positivo, tanto nas questões genéricas quanto nas específicas.Em relação à história de uso de drogas, não foi encontrada diferença estatisticamente significante, entre usuários e não usuários de drogas, tanto nas questões genéricas quanto nas específicas. No consumo alcoólico, apenas uma questão do domínio específico do LDQOL, Preocupações com a Doença, mostrou significância estatística, p = 0.024, onde, os pacientes com alcoolismo crônico apresentaram menor qualidade de vida. Em relação ao gênero, houve diferença estatisticamente significante nas questões genéricas e específicas. As mulheres apresentaram pior qualidade de vida quando comparadas aos homens. Conclusões: Há diminuição da qualidade de vida em pacientes portadores de hepatopatia pelo VHC mesmo nos estágios iniciais da doença hepática. A aplicação do LDQOL permitiu avaliação mais ampla do assunto em questão.As mulheres apresentam pior qualidade de vida. Os pacientes em tratamento antiviral com a negativação do RNA-VHC apresentaram melhor qualidade de vida, sugerindo a existência de um fator biológico responsável por essas alterações. HCV hepatitis is one of the most common causes of liver disease. Worldwide prevalence is estimated to be between 1% and 5%, with approximately 180 million infected people. It is now known that, as happens with other diseases, both emotional problems and the actual assessment of the patient’s state of health may be affected in patients with HCV hepatitis. Objectives: The main objective of this study was to assess the Health Related Quality of Life (HRQOL) in candidates a blood donation who are HCV carriers. Methods: We studied 120 patients who were recently aware of their serostatus. Of these patients, 63% were men and the average age was 38.6(11.0). The patients were divided into three groups according to the severity of the disease: Group A (n = 37) - patients without an indication for liver biopsy; Group B (n = 83) – patients with an indication for liver biopsy; B.1 without an indication for antiviral treatment, i.e. architectural changes in the liver < 2 and/or periportal activity ≤ 2 n=40; B.2 with indication for antiviral treatment, i.e. architectural changes in the liver ≥ 2 and/or periportal activity >2 n=43. The control group was made up of 120 blood donors matched by gender and age that were anti-HCV negative. The following comparisons were done: a) between the HCV patients and control group b) among the three groups of patients with different staging of the disease c) evaluation of changes over time and by treatment d) between genders e) study of comorbidity, alcohol and drugs. In group B.2, the patients who were still HCV-RNA-positive and those who had become HCV-RNA-negative were compared in the sixth month of treatment. We used two questionnaires to evaluate the quality of life: the generic SF 36 and the LDQOL, constituted by the SF 36 plus 75 specific questions for liver diseases. The SF 36 was used to compare the HCV patients with the controls, and the LDQOL to evaluate all patients. Results: Differences were found in comparisons between patients with HCV and the paired controls, with patients having lower scores than the control group. There was an increase in the number of changed domains according to the stage of the disease. For groups A, B.1 and B.2 these increases were five, seven and eight respectively. When the patients were compared in terms of the severity of the disease, no statistically significant difference was found in the SF 36 domains. Statistically significant differences were found, however, in specific questions “Symptoms of the Liver Disease" (p = 0.041), “Concentration" (p=0.035), and “Stigma of the Liver Disease" (p=0.024). In longitudinal comparisons, patients without an indication for liver biopsy and the group which was biopsied without an indication for antiviral treatment showed changes in the LDQOL specific domain “Stigma of the Liver Disease", where there was a reduction in quality of life in the sixth month of follow up. However, the last group had an improvement in the specific domain “Health distress" in the sixth month of follow up. The group undergoing treatment showed changes over time, with a reduction in quality of life in generic and specific LDQOL questions. In this group, the patients receiving treatment who had become HCV-RNA-negative showed better quality of life at the end of the sixth month both for generic and specific questions compared with those who remained HCV-RNA-positive. No statistically significant difference was found in relation to history of drug use either in generic or specific questions. With regard to alcohol consumption, only one question in the specific domain of the LDQOL showed a statistically significant difference, namely “Health distress" (p=0.024). Patients with chronic alcoholism had a lower quality of life in this domain. There was a statistically significant difference in the generic and the specific questions in relation to gender. Women had a poorer quality of life compared with men. Conclusions: There is a reduction in the quality of life of HCV patients even in the initial stages of liver disease. Women have a poorer quality of life. Patients receiving antiviral treatment who became HCV-RNA-negative showed a better quality of life, suggesting a biological factor may be responsible for these changes. Use of the LDQOL allowed a more comprehensive evaluation of the matter in question.

Objetivos: Verificar a tendência do seguro saúde enquanto atividade econômica. Verificar quais são as conseqüências da nova regulamentação sobre as seguradoras. Métodos: Foram realizadas entrevistas em uma amostra intencional de companhias de seguros, situadas no Município de São Paulo, para a coleta de dados, através de dois questionários. O primeiro foi destinado à coleta de informações sobre a empresa como um todo e sobre ramo seguro saúde, em especial. O segundo foi estruturado para coletar dados sobre a interferência da nova regulamentação do setor de medicina supletiva sobre o seguro saúde. O período desta pesquisa refere-se aos anos de 1996 a 2000. Resultados: Quando questionadas sobre a companhia de seguro como um todo. A, C e D afirmaram ter resseguro desde a fundação das empresas. Quanto ao crescimento do número de beneficiário do ramo saúde, a empresa A teve uma amplitude de variação de (11) a 27% com uma média de 8% de crescimento no período. A empresa B variou de 3 a 55% com uma média de 23% e a D, variou de 3 a 21 % com uma média de 10% de crescimento. A empresa A teve uma amplitude de variação do seu prêmio de R$54,62 a R$97,54 com uma tendência crescente no decorrer do período de 5 anos: a empresa B. variou de R$275,00 a R$395,00, aumentando seu prêmio nos 3 primeiros anos e diminuindo nos 2 últimos. A empresa C teve prêmio médio per capita de R$92,19 em 2000 e a D. variou de R$66,00 a R$93,00 e apresentou também crescimento no período de 4 anos. O faturamento anual por beneficiário do seguro saúde. Podemos observar que a empresa A teve uma amplitude de variação de R$655 a R$1.170, com faturamento crescente no período. A empresa B variou de R$3.300 a RS4.740. A empresa C teve um faturamento anual por beneficiário de R$1.104 em 2000 e finalmente, a empresa D variou entre R$788 e R$1.113, apresentando faturamento crescente no período. Conclusão: A amostra aqui estudada representou no ano de 2000, 14% do total das empresas identificadas pela ANS, cerca de 50% do faturamento, 45% do total de beneficiários de seguro saúde no país e 1,6% do total da população brasileira. Antes de qualquer coisa é importante salientar que essas empresas ainda não possuem um sistema de informações gerenciais que possibilite uma maIor análise. Todas as empresas da amostra apresentaram um importante aumento do faturamento do ramo saúde e do número de beneficiários e em todas há uma nítida predominância dos planos empresas. Objectives: To verity the trends of health insurance as a business activity. To check the consequences of the new insurance rulings for insurance companies. Method: Interviews. using two questionnaires. were carried out in order to collect information from a sampling of international insurance companies, located in the City of São Paulo during the years of 1996 to 2000. The aim of the first questionnaire was to gather information about the company as a whole and, specifically, about the health insurance segment. The second questionnaire was structured to collect data about the interference of the new ruling by the area of Supplementary Health Care regarding health insurance. Results: The source of capital of the four companies involved in this study is private. When questioned about the company as a whole, companies A, C and D stated that they have been involved in insurance since their foundation. Regarding the growth in number of beneficiaries in the health insurance area. company A reported a variation of (11) to 27% with an average growth of 8% for the period. Company B reported a variation of 3 to 55% with an average growth of 23%, and Company D reported a variation of\' 3 to 21% with an average growth of 10%. Premium variation for Company A varied from R$54,62 to R$97,54 with a growth trend at the end of the period of 5 years: and Company B. varied from R$275,00 to R$395,00, increasing its premium during the first 3 years and reducing it during the last 2. Company C had an average premium per capita of R$92,19 in 2000 and Company D varied from R$66,00 to R$93,00, also showing growth for a period of 4 years. Annual invoicing per health insurance beneficiary: it can be seen that Company A had a variation from R$655 to R$1.170, with increased invoicing during the period. Company B varied from R$3.300 to R$4.740. Company C reported annual invoicing per beneficiary of R$1.104 in 2000 and, finally, Company D varied between R$788 e R$1.113, showing increased invoicing for the period. Conclusion: The sample studied herein represented. for the year 2000, 14% of the total number of companies identified by ANS, approximately 50% of its invoicing, 45% of the total number of beneficiaries of health insurance found in the country, and 1,6% of the entire Brazilian population. In the first place, it is important to point out that these companies still do not possess an information management system that would allow deeper analysis. All the companies included in the study showed a significant increase in their invoicing in the field of health insurance, number of beneficiaries and all predominantly offer corporate insurance plans.

Objetivo. O presente trabalho tem por objetivo contribuir para a compreensão das alianças estratégicas em organizações de saúde, suas diferentes possibilidades de desenvolvimento e de implementação. Dentre os objetivos específicos constam os aspectos relacionados ao caso escolhido - o grupo de hospitais realizando compras em conjunto, suas atividades, características e mecanismos de ação, fatores restritivos e propulsores que interferem no desempenho do grupo estudado, e aspectos da interação dos hospitais envolvidos. Método. Revisão bibliográfica sobre o tema é seguida do estudo de caso de um grupo de oito hospitais brasileiros que realizam compras em conjunto como um primeiro passo para o estabelecimento de uma aliança. Resultados. A formação do grupo foi facilitada pelas semelhanças existentes entre os hospitais, que vão desde a complexidade dos serviços prestados, passando pelo posicionamento no mercado em que se inserem, incluindo a visão compartilhada de desafios mercadológicos a serem enfrentados nos próximos anos. As atividades conjuntas de compras desenvolvidas pelos hospitais são descritas. O trabalho em torno de um mesmo objetivo, a aproximação de organizações até então acostumadas à relação de concorrência constituem etapa necessária para a construção da viabilidade do grupo. Desta atividade conjunta resulta a intensificação das trocas de informação e o delineamento das possibilidades de expansão desta atividade. A percepção dos dirigentes desses hospitais sobre a iniciativa, seu potencial de desenvolvimento, suas vantagens e desvantagens é relatada e analisada, apontando a relevância, pertinência e viabilidade da proposta de formação de alianças em organizações de saúde. Conclusão. O entendimento da condição de aliança não é homogêneo e a aliança estudada encontra-se em formação. A operação de um grupo de compras em conjunto para o caso estudado é considerada uma estratégia eficaz para o desenvolvimento de uma aliança estratégica entre hospitais, sendo que o envolvimento dos diferentes níveis hierárquicos organizacionais é fator crítico neste processo. Objective: The objective of this work was to contribute to the understanding of strategic alliances in healthcare organizations, the different possibilities in their development and implementation. The specific objectives discussed are: a group of hospitais making purchases together, their activities, characteristics and mechanism of action, restrictive and motivating factors that interfere with group development, and interactions amongst hospitals involved. Method: Review of current literature regarding the subject followed by a case study involving the collaboration of 8 Brazilian hospitais to estabiish combined purchasing power as a first step in the development of a strategic alliance. Results: The formation of such a group was attainable because of the existing similarities between the hospitais involved such as: complexity of services provided, competition within the marketplace, and a common vision of the potential difficulties to be encountered in the near future. The combined buying activities are described. The approximation of the diverse institutions into a unified group with a similar objective was a necessary step in the viability of such an alliance. The results of this endeavor resulted in the exchange of information and the possibility for expansion of such an activity into other common settings. The perception of hospital directors regarding this initiative, its potential for development, advantages and disadvantages are detailed and analyzed discussing the relevance, pertinence, and viability of a proposal for a strategic alliance amongst healthcare organizations. Conclusion: In general, the concept of a strategic alliance is not homogeneous amongst all participants and is still evolving. The use of combined buying power was considered an effect strategy for the initiation of a strategic alliance between hospitals. In addition, the involvement of different levels of hierarchical organizational was a critical factor to the success of such a project.