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ÍNDICE/INDEX
ÍNDICE/INDEX .............................................................................................................................................. 3
Comissão Científica / Scientific Committee .................................................................................................. 4
Comissão Organizadora/ Organizing Commitee........................................................................................... 4
Informação Geral / General Information ....................................................................................................... 5
Programa/ Program .................................................................................................................................... 10
Resumos / Abstracts ................................................................................................................................... 21 Sessões Plenárias/ Plenary Sessions ........................................................................................................ 21 SESSÃO PLENÁRIA I / PLENARY SESSION I .......................................................................................... 22 SESSÃO PLENÁRIA II / PLENARY SESSION II ........................................................................................ 22 SESSÃO PLENÁRIA III / PLENARY SESSION III ...................................................................................... 23
Resumos / Abstracts ................................................................................................................................... 25 Comunicações Orais/Oral Presentations .................................................................................................... 25 SESSÃO 1: Sistemas de Saúde I ............................................................................................................... 26 SESSÃO 2: Measuring performance (English stream) ............................................................................... 28 SESSÃO 3: Oferta e procura de cuidados de saúde .................................................................................. 31 SESSÃO 4: Equidade e determinantes sociais da saúde ........................................................................... 33 SESSÃO 5: Hospital economics (English stream) ...................................................................................... 36 SESSÃO 6: Medição de resultados em saúde ........................................................................................... 39 SESSÃO 7: Economia hospitalar ................................................................................................................ 42 SESSÃO 8: Assessing changes and trends (English stream) .................................................................... 44 SESSÃO 9: Custos em saúde .................................................................................................................... 46 SESSÃO 10: Sector do medicamento ........................................................................................................ 48 SESSÃO 11: New approaches for old issues (English stream) .................................................................. 51 SESSÃO 12: Qualidade de vida ................................................................................................................. 54 SESSÃO 13: Avaliação económica ............................................................................................................ 57 SESSÃO 14: Ageing (English stream) ........................................................................................................ 60 SESSÃO 15: Sistemas de saúde II ............................................................................................................. 63
Resumos / Abstracts ................................................................................................................................... 67 POSTERS ................................................................................................................................................... 67 SESSÃO POSTERS A ................................................................................................................................ 69 SESSÃO POSTERS B ................................................................................................................................ 75
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COMISSÃO CIENTÍFICA / SCIENTIFIC COMMITTEE
Lara Ferreira – ESGHT/U. Algarve (Presidente) Manuel Gomes – University College London
Alberto Holly – U. Lausanne / NHI NOVASBE/UNL Marisa Miraldo – Imperial College
Ana Sofia Pinto Borges – ERS Marta Soares – CHE/U. York
Carlos Gouveia Pinto – ISEG, CISEP/U. Lisboa Miguel Gouveia – Catolica Lisbon SBE
Carlota Quintal – FE/U. Coimbra - CeBER Mónica Oliveira – IST/U. Lisboa
Céu Mateus – Lancaster University Nuno Sousa Pereira – FE/U. Porto
Cláudia Furtado – INFARMED Óscar Lourenço – FE/U. Coimbra - CeBER
Eliana Barrenho – Imperial College Paula Veiga Benesch – EEG/U. Minho
Helena Szrek – CEF.UP/Porto Business School Pedro Pita Barros – NOVASBE/UNL
João Marques Gomes – NHI NOVASBE/UNL Pedro Saramago – CHE/U. York
João Pereira – ENSP/UNL Sara R. Machado – LSE
Julian Perelman – ENSP/ UNL Sílvia Sousa – EEG/U. Minho
Luís Nobre Pereira – ESGHT/U. Algarve Susana Oliveira – FE/U. Porto
Luís Silva Miguel – CEMBE/U.Lisboa Vitor Raposo – FE/U. Coimbra
COMISSÃO ORGANIZADORA/ ORGANIZING COMMITEE
Óscar Lourenço (Presidente) Micaela Antunes Carlota Quintal Vitor Raposo Inês Teixiera
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INFORMAÇÃO GERAL / GENERAL INFORMATION
Certificados de presença / Attendance certificates
Os certificados de presença são distribuídos na entrega de documentação juntamente com o crachá.
Attendance Certificates will be distributed with the conference documentation and the badge, upon registration.
Utilização de crachás / Badges
A utilização do crachá distribuído a cada participante é obrigatória em todas as sessões do programa científico.
Participants are required to wear the badges during the conference events.
Almoço / Lunch
Os almoços serão servidos no restaurante do Hotel Vila Galé, Coimbra.
Lunchs will be served at Hotel restaurant.
Jantar da Conferência / Dinner
O Jantar da Conferência realiza-se na quinta-feira, dia 12, no Restaurante Loggia, e tem início às 20h. O Restaurante Loggia localiza-se junto do Museu Nacional de Machado de Castro, Largo Drº José Rodrigues (ver mapa).
The conference dinner will take place on Thursday, October 12, in Loggia Restaurant.
Sessão de Abertura / Opening Session
A Sessão de Abertura decorrerá entre as 9h30 e as 10h do dia 12 de Outubro.
The opening session will take place between 9:30 am and 10:00 am on October 12th.
Sessão de Encerramento / Closing Session
A Sessão de Encerramento decorrerá entre as 17h e as 17h30m do dia 13 de Outubro.
The closing session will take place between 5:30 pm and 5:00 pm on October 13t.
Sessão de posters / poster session
Os posters apresentados à 15ª Conferência estão disponíveis para visualização nas Salas Julieta, Copélia e Giselle.
The posters will be on display in Rooms Julieta, Copélia e Giselle.
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MAPAS / MAPS
Hotel Vila Galé Coimbra. R. Abel Dias Urbano – 00351 239 240 000
ENDEREÇO/ADDRESS
Rua Abel Dias Urbano, 20
3000-001 Coimbra
Portugal
GPS
N40º 12’ 51’’ - W8º 26’08’
WEBSITE
www.vilagale.com/pt/hoteis/centro-de-portugal/vila-gale-coimbra
TELEFONE/PHONE
(+351) 239 240 000
FAX
(+351) 239 240 050
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Restaurante Loggia: Jantar, 12 de Outubro (Dinner, October 12)
ENDEREÇO/ADDRESS
Museu Nacional de Machado de Castro,
Largo Dr. José Rodrigues
3000-236 Coimbra
Portugal
WEBSITE
www.loggia.pt
TELEFONE/PHONE
(+351) 239 853 076
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APOIOS E PATROCÍNIOS / SPONSORS AND SUPPORT
A organização da 15ª Conferência Nacional de Economia da Saúde agradece às seguintes entidades:
Gilead Amgen Sanofi Sauda Roche
ORGANIZAÇÃO Associação Portuguesa de Economia da Saúde Escola Nacional de Saúde Pública Universidade Nova de Lisboa Avenida Padre Cruz 1600-560 Lisboa - Portugal http://www.apes.pt
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PROGRAMA / PROGRAM
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PROGRAMA/ PROGRAM
Quinta-feira, 12 Outubro 2017
9.00 - 19.00 Acreditação junto do secretariado
9.30 - 10.00 Sessão de abertura Sala Julieta
10.00 - 11.00 Sessão Plenária - I Sala Julieta
Moderador Céu Mateus
When populations are coming to age
Rudi GJ Westendorp
Center for Healthy Ageing; Department of Public Health, University of Copenhagen
11.00 - 11.30 Coffee Break
11.30 - 13.00 Sessões Paralelas (1-2-3)
Sessão 1 Sistemas de Saúde I Sala Julieta
Moderador Sílvia Sousa
Improving quality in Portuguese primary care using geographical and patient satisfaction data
Pedro Lopes Ferreira, Vítor Raposo What future for healthcare expenditures? A time series analysis
Sofia Cruz Gomes, Mário Lopes, Bernardo Almada-Lobo Stakeholders' views on public involvement in policy making in the Portugal
Ceu Mateus, Sofia Crisostomo, Margarida Santos
Análise de Eficiência das Unidades Locais de Saúde: uma aplicação da Data Envelopment Analysis
André Moreira, Álvaro Almeida
Avaliação do Rastreio do CCU na Região de Saúde do Centro: Impacto do Rastreio na mortalidade
Sandra Lourenço, Óscar Lourenço, Daniel Pereira da Silva
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Sessão 2 Measuring Performance (English stream) Sala Copélia
Moderador Eliana Barrenho
The role of advanced nurse practitioners in achieving health gains and quality of care
Mário Amorim Lopes, Sofia Cruz Gomes, Bernardo Almada-Lobo
The Impact of Organizational Change on Firm Efficiency: Evidence from the Healthcare Sector
Renata Kosová, Giorgia Marini, Marisa Miraldo, Mujaheed Shaikh
Health care system efficiency and burden of disease: An international comparison using Distance Direction Function
Julio Souza, João Santos, Ana Camanho, João Viana, Alberto Freitas What drives hospital boards performance?
Alexandre Lourenço, Pita Barros
Retirement and Health Plan choices: Evidence from Swiss Administrative Data
Mujaheed Shaikh, Tobias Mueller, Lukas Kauer
Sessão 3 Oferta e procura de cuidados de saúde Sala Giselle
Moderador Óscar Lourenço
Impact of vertical integration on the readmission of individuals with chronic conditions
Óscar Brito Fernandes, Rui Santana, Sílvia Lopes
Benchmarking nos Cuidados de Saúde Primários na região Centro: o desempenho relativo como mecanismo de competição
Isabel Morais-Henriques, Susana Oliveira, Elvira Silva
The Health Production Function Revisited: The Role of Social Networks and Liquid Wealth
Carolina Santos, Pedro Pita Barros
Towards a balance between physicians’ supply and demand, equity of physicians across specialties and cost considerations: Developing a comprehensive tool to assist health workforce training
Marta Monteiro, Teresa Cardoso-Grilo, Mónica Oliveira, Ana Barbosa-Póvoa, Mário Amorim Lopes
Evaluating the Impact of Physicians’ Provision on Primary Healthcare: evidence from Brazil’s More Doctors Program
Luiz Felipe Fontes, Otavio Canozzi Conceição, Paulo de Andrade Jacinto, Mauricio Saraiva
13.00 - 14.30 Almoço
14.30 - 16.00 Sessões Paralelas (4-5-6)
Sessão 4 Equidade e determinantes sociais da saúde Sala Julieta
Moderador Mónica Oliveira
Geographic Variation in Healthcare Expenditure in the Netherlands: Evidence from Movers
Ana Moura, Martin Salm, Rudy Douven, Minke Remmerswaal
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Making the case for the standardisation of unmet health care needs across Europe
Óscar Lourenço, Micaela Antunes, Carlota Quintal, Luis Mora Ramos
Social capital and health deprivation: an exploratory analysis based on ESS data
Micaela Antunes, Óscar Lourenço, Luís Moura Ramos, Carlota Quintal
Determinantes da prevalência de tempo em frente à TV de adolescentes no Brasil
Cássia Kely Favoretto Costa, Marina Silva da Cunha, Olívia Takahashi Margarido, Flávia Fernanda da Silva Machado
Effect of socioeconomic factors on health: a closer look at municipalities Raquel Duarte, Rita Gaio, Milton Severo, Alvaro Almeida
Condições econômicas afetam o estilo de vida dos indivíduos? Evidências de microdados para o Brasil
Lívia Madeira Tríaca, Paulo de Andrade Jacinto, Cesar Augusto Oviedo Tejada, Marco Túlio Aniceto França
Sessão 5 Hospital Economics (English stream) Sala Copélia
Moderador
Sara Machado
Towards improved surgical decision-making: A multimethodology to understand variability in surgeons' choice of treatments and to build a decision support model
Liliana Freitas, Mónica Oliveira, Teresa Cabral Braga, João Coutinho, José Mendes de Almeida, Carlos Bana e Costa
Are incentives driving day surgery pratice in Portuguese public hospitals?
Sílvia Sousa, Paula Veiga
An inside look into HAIs: Resources and strategies in health organizations
Sandra Oliveira, Sofia Ferreirinha, Hugo Sousa, Carla Cordeiro, Ana Tavares, Claudia Simão
Desperately searching high users of hospital emergency services Inês Catarino, Pedro Pita Barros
Time trend of avoidable hospitalization and their related charges in Portugal
João Vasco Santos, Júlio Souza, Manuel Gonçalves-Pinho, João Viana, Alberto Freitas
Sessão 6 Medição de resultados em saúde Sala Giselle
Moderador Julian Perelman
Overcoming common critical mistakes in building population health indices
through the MACBETH socio-technical approach
Ana Vieira, Mónica D. Oliveira, Teresa Rodrigues, João Bana e Costa, Ângela Freitas, Liliana Freitas, Paula Santana, Carlos Bana e Costa
Controlo de qualidade dos dados na valoração portuguesa do EQ-5D-5L
Patricia Antunes, Pedro Ferreira, Lara Ferreira
Estimation of the EQ-5D-5L value set for Portugal
Pedro Ferreira, Lara Ferreira, Luís Pereira, Patrícia Antunes
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Medição da qualidade de vida relacionada com a saúde em doentes com psoríase: resultados do estudo pessoa em comparação com população portuguesa
Ines Moital, Lara Noronha Ferreira, Sofia Oliveira-Martins, Pedro Laires, José Cabrita
Tackling network meta-analysis methodological challenges: a case study on biologic treatments for moderate to severe plaque psoriasis in children and young people
Pedro Saramago, Ana Duarte, Stephen Palmer, Claire Rothery
16.00 - 16.30 Coffee Break
16.30 - 17.30 Sessões Paralelas (7-8-9)
Sessão 7 Economia Hospitalar Sala Julieta
Moderador Alexandre Lourenço
Doctors' Response to Queues: Evidence from Portuguese Emergency Rooms
Bruno Martins, Luís Filipe
Overestimation of health urgency as a cause for emergency services inappropriate use: an exploratory economics experiment
Anabela Botelho, Isabel Correia , Tania Fernandes, Ligia Pinto, Jorge Teixeira, Marieta Valente, Paula Veiga
Understanding avoidable caesarean sections: Are hospital characteristics important?
Ceu Mateus, Carla Nunes
Volume-outcome effect, learning-by-doing e economias de Escala no setor hospitalar brasileiro: o caso da artroplastia de quadril (Rip Replacement)
Pedro Henrique Soares Leivas, Paulo de Andrade Jacinto, Anderson Moreira Aristides dos Santos, César Augusto Oviedo Tejada
Sessão 8 Assessing changes and trends (English stream) Sala Copélia
Moderador Pedro Saramago
Changes in access to primary care and its socioeconomic patterning in Europe, 2007-2012
Klára Dimitrovová, Julian Perelman
Developing models for improving efficiency and access and for reducing costs in the operating room
Inês Marques, M. Eugénia Captivo, Mónica Oliveira, Ana Barbosa-Póvoa, Nuno Ramos
Health Expenditure and Economic Growth: A Panel Vector Error Correction model for 25 OECD European countries
Joana Cima
An innovative payment model for the Portuguese mental health system
Julian Perelman, Maria Ana Matias
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Sessão 9 Custos em saúde Sala Giselle
Moderador Miguel Gouveia
Custo do tratamento do cancro em Portugal
José Machado Lopes, Francisco Rocha Gonçalves, Marina Borges, Patrícia Redondo, José Laranja-Pontes
Comparison of healthcare costs between an implemented Integrated Diabetes Care unit and the traditional National Health System
Rogério Ribeiro, Alejandra Guillén, Luis Gardete Correia, José Manuel Boavida, Jorge Posada, João Filipe Raposo
Treatment Cost of Serious Mental Illnesses in Portugal
Maria Ana Matias, Julian Perelman
Hospitalized patients with schizophrenia in Portugal: clinical characterization and costs
Francesca Fiorentino, Raquel Ascenção, Miguel Gouveia, João Pascoal, João Costa, Margarida Borges
17.45 - 18.45 Poster Sessions (A e B)
Poster A Sistemas de saúde: desempenho, financiamento e equidade I Sala Copélia
Moderador Ana Teresa Paquete e Gisele Braun
Cost-effectiveness Analysis of Crizotinib for Untreated Anaplastic Lymphoma Kinase-Positive Advanced Non-Small-Cell Lung Cancer in Portugal
Pedro Saramago, Monica Ines, Frederico Saraiva
Estilos de vida e saúde auto avaliada: uma análise estratificada por renda para o Brasil
Lívia Madeira Tríaca, Marco Túlio Aniceto França, Cesar Augusto Oviedo Tejada, Marília Cruz Guttier
Avaliação dos custos da Consulta de Planeamento Familiar da USF da Barrinha em 2016
Isabel Tomás, Cristina Coelho, Fernando Fardilha, Isabel Gomes, Marília Diogo, Tiago Carvalho, Lima Nogueira, Inês Trigo, Constança Oliveira, Cristiana Conceição, Clara Silva
Análise Custo Efetividade da Metadona, como tratamento de manutenção
Davide Cruz, Oscar Lourenço, José Almeida
Health-related quality of life in patients with transthyretin familial amyloid polyneuropathy in Portugal
Mónica Inês, Teresa Coelho, Isabel Conceição, Teresa Bago D'Uva, Mamede Carvalho, João Costa
Prevalence of transthyretin familial amyloid polyneuropathy in Portugal during year 2016
Mónica Inês, Teresa Coelho, Isabel Conceição, Filipa Duarte-Ramos, Mamede Carvalho, João Costa
Desigualdade socioeconômica na mortalidade infantil no Estado da Bahia/Brasil, 2000-2010
Péres Geandry, Perelman Julian
Primary care user's voice in Portugal: did patient satisfaction changed with the new organizational models?
Pedro Ferreira, Vítor Raposo
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Satisfação profissional dos Médicos de Anatomia Patológica em Portugal Domingos Oliveira, Pedro Ferreira Monitorização da satisfação dos utilizadores dos cuidados de saúde
primários: os últimos 25 anos Pedro Ferreira, Vítor Raposo
Poster B Sistemas de saúde: desempenho, financiamento e equidade II Sala Giselle
Moderador Susana Oliveira e Paula Veiga
Determinantes socioeconômicos e ambientais na incidência e mortalidade por câncer de mama: análise cienciométrica, 2006 - 2016
Cássia Kely Favoretto Costa, Olívia Takahashi Margarido, Ednaldo Michellon
O impacto da arrecadação municipal e das transferências estaduais sobre o Índice de Desenvolvimento Humano (Longevidade) dos municípios paranaenses (2000-2010)
Kézia Bondezan, Gabrielle Garcia
Perfil de morbidade, gastos e permanência hospitalar por acidentes de trânsito com motociclistas no Paraná, Brasil
Marina Magalhães Camora, Cássia Kely Favoretto Costa, Eraldo Schunk da Silva, Marcos Brambilla, Ely Mitie Massuda
High effectiveness and clinical safety with daclatasvir in real-life
Ana Morbey, Cristina Valente, Fátima Serejo, Rui Tato Marinho, Rui Sarmento e Castro, Alexandra Martins, Isabel Pedroto, Armando Carvalho, Paula Peixe, Fernando Maltez, José Velosa, Catarina Silva, Miguel Faria
Socioeconomic inequalities in the prevalence of multimorbidity in Portugal: results from the fifth National Health Interview Survey 2014
Sónia Romano, Irina Kislaya, Joana Esparteiro, Ausenda Machado
Equidade na prestação e financiamento em saúde
Marta Frias Borges, Filomena Girão, Carlos Costa Gomes
Weekend effect no setor hospitalar brasileiro: o caso de infarto agudo do miocárdio
Pedro Henrique Soares Leivas, Paulo de Andrade Jacinto, Anderson Moreira Aristides dos Santos, César Augusto Oviedo Tejada
Intervenção coronária percutânea em hospitais especializados e hospitais gerais: uma análise empírica para o Brasil
Pedro Henrique Soares Leivas, Paulo de Andrade Jacinto, Anderson Moreira Aristides dos Santos, César Augusto Oviedo Tejada
Sistemas de notificação de dispositivos médicos inovadores na área da diabetes: o caso português
Vânia Sousa, Paula Benesch, Maria Olívia Pereira
20h Jantar da Conferência
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Sexta-feira, 13 Outubro 2017
9.30 - 11.00 Sessões paralelas (10-11-12)
Sessão 10 Sector do Medicamento Sala Julieta
Moderador Claudia Furtado
Brand authenticity and health care: does it apply? Pedro Barros, João Marques Gomes
Political factors and pharmaceutical markets regulations in OECD countries Sónia Queirós, Maria de Lurdes Martins, Michael Baum
Sequências terapêuticas no tratamento da diabetes tipo 2: primeira abordagem
Teresa Risso, Inês Ramos, Cláudia Furtado
The regional equity impact of community pharmacies on the access to a needle exchange program
Miguel Gouveia, Margarida Borges, Francesca Fiorentino, Gonçalo Jesus, José Pedro Guerreiro, Maria Cary, Suzete Costa, António Vaz Carneiro
Cost function for the Portuguese community pharmacies Isabel Correia, Tatiana Loureiro, Queirós, Paula Veiga
Sessão 11 New approaches for old issues (Stream in English) Sala Copélia
Moderador Teresa Bago D'Uva
Cost-effectiveness of high-throughput, non-invasive prenatal testing for fetal rhesus D status
Pedro Saramago, Stephen Palmer, Susan Griffin
Enhancing Health Technology Assessment through Multicriteria Decision Analysis: A roadmap of methods and tools to tackle challenges in the evaluation of medical devices
Mónica Oliveira
Estimating treatment effects under untestable assumptions with non-ignorable missing data: clarifying common misconceptions about the use of selection models
Manuel Gomes, Michael Kenward, Richard Grieve, James Carpenter
The role of physician and environment-specific factors in the adoption behaviour of new technologies
Eliana Barrenho, Marisa Miraldo, Carol Propper, Ana Wheelock, Mauro Laudicella
Expectations and risk attitudes: Evidence from a longitudinal survey in Tshwane, South Africa
Rui Leite, Li-Wei Chao, Helena Szrek
Home is where your health is: the impact of internal migration on health and wellbeing
Jack Higgins, Bruce Hollingsworth, Ian Walker
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Sessão 12 Qualidade de vida Sala Giselle
Moderador Carlos Gouveia Pinto
Real-world evidence on heart failure: findings from 25 thousand patients in a
portuguese primary care database
Raquel Ascenção, Francesca Fiorentino, Miguel Gouveia, João Costa, Paula Broeiro, Cândida Fonseca, Margarida Borges
EQ-5D: o que se ganha com a mudança do 3L para o 5L? Luis Nobre Pereira, Pedro Lopes Ferreira, Lara Noronha Ferreira, Patrícia Antunes
Levels and Determinants of Self-Medication in Portugal Patrícia Pinto e Filipe, Pedro Pita Barros
Transthyretin familial amyloid polyneuropathy impact on health-related quality of life
Mónica Inês, Teresa Coelho, Isabel Conceição, Lara Ferreira, Mamede Carvalho, João Costa
Normas portuguesas do EQ-5D-5L Lara N. Ferreira, Pedro L. Ferreira, Luis N. Pereira, Patricia Antunes
11.00 - 11.30 Coffee Break
11.30 - 12.30 Sessão Plenária II Sala Julieta
Moderador Pedro Pita Barros
The opportunities and challenges of innovations in data collection in panel studies:
lessons from Understanding Society (the UK household longitudinal study)
Michaela Benzeval
Institute for Social and Economic Research
University of Essex, Reino Unido
12.30 - 14.00 Almoço
14.00 - 15.30 Sessões paralelas (13-14-15) Sala
Sessão 13 Avaliação económica Sala Julieta
Moderador Luís Silva Miguel
Real-world comparative treatment effectiveness in early-onset transthyretin familial amyloid polyneuropathy patients
Mónica Inês, Teresa Coelho, Isabel Conceição, Marta Soares, Mamede Carvalho, João Costa
Vacina anti-HPV universal: avaliação económica em Portugal Filipa Quinteiros
Cost-Effectiveness of Pembrolizumab for the first-line treatment of metastatic non-small cell lung carcinoma in Portugal
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Bernardete Pinheiro, Joana Alarcão, Luís Silva Miguel, Min Huang, Sheenu Chandwani, Francisca Lopes, Margarida Borges
Economic evaluation of the portuguese needle exchange programme in community pharmacies
Margarida Borges, Miguel Gouveia, Francesca Fiorentino, Gonçalo Jesus, Maria Cary, José Pedro Guerreiro, Suzete Costa, António Vaz Carneiro
An economic evaluation of a complex nutrition intervention to prevent vitamin D deficiency
Magda Aguiar, Lazaros Andronis, Miranda Pallan, Wolfgang Högler, Emma Frew
Sessão 14 Ageing (English stream) Sala Copélia
Moderador Manuel Gomes
The cost of social isolation for elderly hip fracture patients in England: delayed discharges
Filipa Landeiro, Seamus Kent, M Kassim Javaid, Ku Shah, Claire Pulford, Alastair Gray, Jose Leal
Partners in Care! Ageing Couples and Informal Caregiving in Europe
Luís Filipe
Estimation of the future impact of the aging of people living with Human Immunodeficiency Virus (HIV) in Portugal
Francesca Fiorentino, Rita Sousa, Miguel Gouveia, Margarida Borges, António Vaz Carneiro, João Costa
Selfie Ageing Index: an index for the self-assessment of healthy and active ageing
Judite Gonçalves, Isabel Gomes, Maria Amália Botelho, Pedro Pita Barros, Miguel Fonseca
Access to Medicines by the Portuguese Elderly Population: Overview
Pedro Pita Barros, Pedro Carvalho
Sessão 15 Sistemas de Saúde II Sala Giselle
Moderador Carlota Quintal
Influência da Organização dos Cuidados de Saúde Primários na Utilização do Serviço de Urgência
Joana Vales , Álvaro Almeida
Does transparency and accountability in health systems means the same for different countries?
Vítor Raposo, Pedro Lopes Ferreira
Determinantes da despesa corrente pública em saúde em Portugal Gisele Braun
Fatores associados com a adoção de normas de orientação clínica no tratamento de infeções urinárias nos Cuidados de Saúde Primários
Ana Catarina Silva, Nuno Sousa Pereira, Susana Oliveira
Função de produção de saúde para o Brasil: análise pelo Modelo de Grossman
José Rodrigo Gobi, Pietro André Telatin Paschoalino, Cássia Kely Favoretto Costa, Marina Silva da Cunha
Efeito da mudança do modelo organizacional nos resultados dos indicadores de desempenho não incentivados em Cuidados de Saúde Primários
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Miguel Azevedo, Álvaro Almeida
15.30 - 16.00 Coffee Break
16.00 - 17.00 Sessão Plenária III Sala Julieta
Moderador
Lara Noronha Ferreira
A Morte Saiu à Rua
Pedro Lopes Ferreira
Faculdade de Economia da Universidade de Coimbra/Centro de Estudos e Investigação em Saúde da Universidade de Coimbra
17.00 - 17.30 Sessão de encerramento Sala Julieta
Nota: Os posters ficarão em exibição durante toda conferência nas três salas (Julieta, Copélia e Giselle)
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RESUMOS / ABSTRACTS
Sessões Plenárias/ Plenary Sessions
22
SESSÃO PLENÁRIA I / PLENARY SESSION I
When populations are coming to age
Rudi GJ Westendorp Department of Public Health, University of Copenhagen
Current lifespans are longer and of higher quality than ever before, whereas disease trajectories have become more complicated and protracted. The appropriate response to this paradox is to invest further in prevention of harm, and in the repair of damage. Citizens, patients, politicians and entrepeneurs alike, all have great expectations of academia as a creator of change, and it is out of this societal crosstalk that the wish for knowledge-and-innovation-communities emerge. Of course, it is an international endeavour as population aging is a universal phenomenon of which the consequences are felt all over Europe. The differences between the countries are food for the scholarly eye: it is the beginning of a better understanding and the start of innovation.
With the baby boom generation coming to age, we should prepare for this development, pioneering with interdisciplinary research, transboundary education and multistakeholder projects. The strive for a healthier life, an active old age, and an improvement of healthcare services can only be understood amidst other grand challenges. How do we make best out of the revolutionizing information technologies? How do we accommodate economic and political shocks? How do we make our societies sustainable? Here we should make best out of the diversity of academic environments and scientific approaches.
To stand still is to go backwards. With my presentation, I’ll introduce you to a journey that we have just begun.
∞
SESSÃO PLENÁRIA II / PLENARY SESSION II
The opportunities and challenges of innovations in data collection in panel studies: lessons from Understanding Society (the UK Household Longitudinal Study)
Michaela Benzeval Institute for Social and Economic Research, University of Essex The fundamental purpose of longitudinal panel studies is to investigate changes over time accurately on a representative sample of the population. This requires consistent repeated measures of key phenomena and maintaining a high response rate. At the same time, new technologies and new approaches to data collection are creating new opportunities; scientific endeavour and policy challenges are constantly evolving requiring new concepts to be incorporated. Balancing consistency over time, while incorporating innovations, is a constant challenge for longitudinal studies.
Understanding Society: the UK Household Longitudinal Study has adopted a range of innovations including: an innovation panel dedicated to methodological experiments; an adaptive design on the main study to facilitate a constant cycle of testing, evaluating and improvements; increasing use of new technologies and other enhancements to capture specific topics in more depth; the inclusion of biomarker, genetic and epigenetic information; and, data linkage to geographic, administrative, social media and commercial data.
∞
23
SESSÃO PLENÁRIA III / PLENARY SESSION III
A Morte Saiu À Rua
Pedro Lopes Ferreira Centro de Estudos e Investigação em Saúde da Universidade de Coimbra
Nesta apresentação será abordada evidência da medição de estados de saúde piores que morte. Este tipo de estados de saúde existe de facto e é percebido e compreendido pelos doentes e pela população em geral. Várias são as técnicas utilizadas para a determinação das preferências cardinais para estados de saúde piores que morte. Por outro lado, a sua utilização é hoje corrente em avaliações custo-efetividade ou custo utilidade.
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RESUMOS / ABSTRACTS
Comunicações Orais/Oral Presentations
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SESSÃO 1: Sistemas de Saúde I
Improving quality in Portuguese primary care using geographical and patient satisfaction data
Pedro Lopes Ferreira1,2, Vítor Raposo1,2,3 1Centre of Health Studies and Research of the University of Coimbra (CEISUC), Coimbra, Portugal, 2Faculty of Economics of the University of Coimbra (FEUC), Coimbra, Portugal, 3Centre for Business and Economics Research (CeBER), Coimbra, Portugal
AIM: Since 2006 several primary-care reforms have been implemented in Portugal by creating new organizational models for healthcare units and reorganizing management units by geographic areas. Previous analysis related with patient satisfaction surveys in 2009 and 2015 show disparity of satisfaction indices by health-administrative regions and, within each, by primary care unit. The aim is to add accurate geographical data considering Portugal NUTs and typology of urban areas (TUA) defined by the National Institute of Statistics (INE) and understand if those elements act as moderators, mediators or confounders.
METHODS: Data from two EuroPEP patient surveys (2009 and 2015) administered in a one-day census sample in primary-care units with different organizational models (traditional model: UCSP; new models: USF-A and USF-B) in the five Portuguese health-regions (North, Centre, Lisbon/Tagus Valley, Alentejo and Algarve). Both surveys focus on four main dimensions: medical care (interpersonal and technical components), non-medical care (nurses and staff), organization (accessibility and the services provided in general), and quality of facilities. Data from health unities address was linked with NUTs (levels 1, 2 and 3) and TUA (three defined areas: predominantly urban, median urban, and predominantly rural) from INE. Application of multivariate analysis.
EXPECTED RESULTS: Characterize the evolution of the organizational models related with health reforms from 2009 to 2015 by NUTs and TUA; identify patient satisfaction asymmetries between NUTs and TUA; find relationships between patient satisfaction dimensions and the geographical data analysis (NUTs and TUA); propose health policy actions to improve equity between geographical areas.
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What future for healthcare expenditures? A time series analysis
Sofia Cruz Gomes1,2, Mário Lopes1,2, Bernardo Almada-Lobo1,2 1FEUP, Porto, Portugal, 2INESC-TEC, Porto, Portugal
The healthcare sector has a major relevance in both social and economic contexts. The rising healthcare expenditures experienced over the last decades have urged researchers to review the determinants of healthcare expenditures. The main goals of this study are to assess the main determinants of health expenditures, to provide a comprehensive understanding on the relationship between expenditures and some of their main determinants and to predict the future healthcare expenditures. Using data from Portugal for the period 1980-2014, we carry out a time series analysis to detect and describe the relationship between healthcare expenditures, economic growth, healthcare workforce and demographic variables. Using projections for the Gross Domestic Product, the size and age of the population, and the number of Health Human Resources, we project healthcare expenditures until 2060. Results show expenditure in healthcare depends on the economic conditions, the demographic structure of the population and on the level of health workforce. The projection of future expenditures based on our results and on what is the expected evolution of those drivers reveals a rising trend in health expenditures, which may generate heightened challenges to governments and managers on the future delivery of healthcare.
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Stakeholders' views on public involvement in policy making in the Portugal
Ceu Mateus1, Sofia Crisostomo2,3, Margarida Santos2,3 1Lancaster University, Lancaster, United Kingdom, 2Centro de Investigação e Estudos de Sociologia (CIES-IUL), ISCTE-IUL, Lisboa, Portugal, 3GAT - Grupo de Ativistas em Tratamentos, Lisboa, Portugal Successful governance for health requires co-production of health, i.e., sharing governance and involving citizens in producing knowledge to inform decision-making. Nevertheless, in Portugal, public involvement has been insufficient and selective, even though individuals and civil society organisations have shown interest to participate in health care decision-making. The recognition of public involvement value by other stakeholders has been considered key to promote citizen representatives involvement in decision-making and health policy. The views, attitudes and experiences of various health stakeholders (decision-makers, policy makers, doctors, nurses, and hospital managers) will be assessed through an online questionnaire and analyzed in face of the public perspective to identify drivers and barriers to a greater and meaningful public involvement in the Portuguese NHS. In order to have the patient in the centre of the system it is key to have public involvement informing policy-making on governance for health.
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Análise de Eficiência das Unidades Locais de Saúde: uma aplicação da Data Envelopment Analysis
André Moreira, Álvaro Almeida Faculdade de Economia da Universidade do Porto, Porto, Portugal
Os ganhos de eficiência obtidos com a integração vertical de cuidados de saúde através do modelo das Unidades Locais de Saúde (ULS) adotado em Portugal não estão ainda devidamente demonstrados. O presente trabalho avalia se as ULS são tecnicamente mais eficientes do que a alternativa de ter agrupamentos de centros de saúde (ACES) organicamente independentes dos hospitais, determina quais as unidades mais eficientes, e analisa a influência da localização e da lotação na eficiência técnica destas instituições.
Através de um modelo de Data Envelopment Analysis (DEA) – modelo de rendimentos constantes à escala orientado para os outputs – em duas fases, comparamos a eficiência técnica das ULS existentes atualmente em Portugal (ULS originais) e as unidades compostas “artificialmente” por combinação dos ACES com os hospitais de referência (ULS sintéticas), tendo por base a rede de referenciação hospitalar de cirurgia geral. Na segunda fase, utilizou-se um modelo de regressão linear múltipla com as características das unidades para explicar os scores de eficiência.
Os resultados mostraram que quatro das oito ULS originais são eficientes, enquanto que as unidades mais eficientes entre as não ULS são oriundas do norte e centro do país. Concluiu-se ainda que as ULS são estatisticamente mais eficientes do que as unidades não ULS. A par disso, verificou-se também que a localização afeta significativamente a eficiência das unidades de saúde, contrariamente ao que acontece com a lotação das instituições.
Conclui-se que a adoção do modelo ULS podem proporcionar ganhos de eficiência.
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Avaliação do Rastreio do CCU na Região de Saúde do Centro: Impacto do Rastreio na mortalidade
Sandra Lourenço1, Óscar Lourenço3, Daniel Pereira da Silva4 1Administração Regional de Saúde do Centro, IP, Coimbra, Portugal, 3Centre for Business and Economics Research (CeBER), Faculdade de Economia da Universidade de Coimbra, Coimbra, 4 Comissão Coordenadora do Programa de Rastreio do Cancro do Útero da ARS Centro, IP, Coimbra, Portugal
Objetivos: O cancro do colo do útero (CCU) é considerado uma doença evitável, que pode ser eficazmente controlado pelo rastreio. A taxa de mortalidade atual (2013) é de 3,7/105 mulheres, inferior a 1955 (11,1/105). A Região Centro tem, desde 1990, um programa de rastreio de base populacional com 100% de cobertura. Sendo pertinente avaliar o efeito deste programa de rastreio, o presente estudo visa analisar o seu efeito na mortalidade por CCU a nível regional.
Dados e Métodos: Os dados provém das estatísticas oficiais do INE, sem ocultação de dados para a quase totalidade dos concelhos, com a única exceção do Concelho de Vila de Rei no ano de 2012. População alvo: total de mortes por CCU em Portugal (2.550) e na Região Centro (389) ocorridas entre 2002 e 2013. Para avaliar o impacto do rastreio do CCU nos 78 concelhos, 6 ACeS e 2 ULS, foi utilizado o método de padronização indireta para a construção do Índice Comparativo de Mortalidade ou Razão Padronizada da Mortalidade (RPM).
Resultados: Das 389 mortes ocorridas na Região, 186 pertenciam ao grupo etário dos 25 aos 64 anos de idade (47,8%), valor inferior ao verificado no Continente (51,6%). Evidenciam-se os “sinais de alerta” com o aumento significativo de mortes observadas face às esperadas (RPM) em alguns locais da Região, por comparação com a população padrão.
Conclusão: A redução significativa da mortalidade por CCU verificada na Região Centro sugere que o programa de rastreio de base populacional contribui para os ganhos em saúde na população feminina dos 25 aos 64 anos.
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SESSÃO 2: Measuring performance (English stream)
The role of advanced nurse practitioners in achieving health gains and quality of care
Mário Amorim Lopes1,2, Sofia Cruz Gomes1,2, Bernardo Almada-Lobo1,2 1INESCTEC, Porto, Portugal, 2Universidade do Porto, Porto, Portugal
Provider shortages and geographical imbalances may result in unmet care needs. The problem is aggravated further when we consider population ageing and the expansion of chronic illnesses and co-morbidities, which suggest a higher demand for health care services in the future. Widening clinical roles for nurses through task-shifting and expansion of scope-of-practice may harness their contribution to mitigating these needs, but also to more effective health care delivery and improved quality of care. However, such organizational change entails great challenges, such as devising nurse residency programs and promoting policies that push the change. In this work we make the case for expanding the clinical roles of nurses in Portugal. To do so, we analyse a wide array of empirical evidence regarding the impact of advanced nursing practitioners (ANPs) in primary care and hospital settings. Second, we conduct a cross-country analysis to understand the impact ANPs have in different health systems, highlighting the experience of countries that feature a health system similar to Portugal. Third, we forecast the impact of implementing nurse residency programs on the nursing workforce and provide estimates of the cost to the public budget. Finally, we provide policy insights and recommendations of how such organizational may be enabled in the Portuguese NHS.
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The Impact of Organizational Change on Firm Efficiency: Evidence from the Healthcare Sector
Renata Kosová1, Giorgia Marini2, Marisa Miraldo1, Mujaheed Shaikh3 1Imperial College Business School, London, United Kingdom, 2Sapienza University of Rome, Rome, Italy, 3Vienna University of Economics & Business, Vienna, Austria
The impact of organizational on firm performance has been central for research in economics. Yet, despite of its importance, empirical evidence is still scant. In healthcare markets most of the evidence relates to the impact of ownserhip on performance, but evidence is mixed. We argue that this ambiguity is due to two reasons: first, these studies compare performance across firms that operate in heterogeneous markets, and such differences are not accounted for empirically. Second, there is little assessment of how organizational change relates to performance as most studies analysed differences across- rather than within- providers over time. We add to the literature by assessing the performance effects of organizational change in the context of a homogenous healthcare market - by analysing the impact on hospital costs and exploring the role of scale and scope economies as channels for generating cost efficiencies. We do so by exploiting the introduction of the Foudation Trust policy that triggered organizational change. Making use of differences-in-differences methodology and exploiting detailed panel-data for English hospitals during 2001-2008 we find that, hospitals exhibit economies of scale, but not scope; hospitals with FT status are more efficient than non-FTs; and the organizational change facilitates economies of scope but not economies of scale. However, efficieny gains vary importantly with various sources of hospital heterogeneity such as teaching status, and relative performance. Our paper suggests that, the FT policy has been effective in enabling cost-efficiencies, highlighting that organizational changes can be instrumental in promoting the long-term sustainability of healthcare systems.
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Health care system efficiency and burden of disease: An international comparison using Distance Direction Function
Julio Souza1,2, João Santos1,2, Ana Camanho3, João Viana1,2, Alberto Freitas1,2 1CINTESIS, Center For Health Technology And Services Research, Porto, Portugal, 2MEDCIDS, Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, 3Faculty of Engineering of the University of Porto, Porto, Portugal
Objectives: This ongoing study aims to evaluate the efficiency of health care systems in 168 countires with respect to Disability-adjusted life years (DALYs), which reflects the gap between the current health status and an ideal health situation.
Methods: We used Distance Direction Function (DDF) to estimate health care system efficiency. Data for 2014 and 2015 was collected from World Health Organization and World bank databases and from the Global Burden of Disease (GBD) tool. Total health expenditure per capita and literacy rate were used as inputs. Life expectancy at birth and age-standardized DALYs rate, which is the main focus of our analysis, were chosen as outputs. Our model was designed to expand life expectancy and to contract DALYs rates. The model also imposes that a given country will only be compared with those on the efficiency frontier with similar or lower input values, ensuring that the expected target outputs are achievable in practice.
Results: Results from an experimental DDF model indicated that countries with discrepant health outcomes were labeled as efficient, which flags the need of restricting the sample to comparable realities. Thus, the definition of clusters to address this issue and also the model specification are currently under debate.
Conclusions: Evaluating health care system efficiency with respect to DALYs have not been explored in the literature. We expect not only to expand the growing number of international comparisons of health care system efficiency, but also to investigate whether available resources can produce better health outcomes, namely the reduction of DALYs.
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What drives hospital boards performance?
Alexandre Lourenço1,2, Pedro Pita Barros1 1Nova School of Business & Economics, Lisboa, Portugal, 2Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
There is a very high degree of controversy about the behaviour of different healthcare providers according to the different governance models (e.g. autonomy level, financing and contractual arrangements, board size, composition and selection). The scientific evidence to opt for a specific model is quite low with dramatic implications into policy-making. International and national organizations have been recommending a set of specific soft and hard skills as criteria for the recruitment of hospital managers. Recently, in Portugal, hospital top managers undergo an evaluation performed by an independent public administration committee (CRESAP) prior to appointment.
First, we analyse the changes on the profile of managers after this new legal framework. Secondly, we study the relationship between board composition characteristics (e.g. gender, age, education, specific training, tenure, experience) and hospital overall performance. For that we performed a desk review of the Portuguese Republic Official Journal, that publishes all new hospital boards appointments. For hospital performance assessment, we use data public published by the Central Administration of the Healthcare System. This allows to trace the main features of appointees to hospital boards and its implications to management quality (as measured by hospital performance).
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The Drivers of Demand for Private Medical Insurance in England.
Ahmed Nur, Isra Hausien, Aqib Chaudry, Ikram-Ul Haq, Nadia Ahmed, Mariam Choudhry, Amar Sodha Imperial College London, London, United Kingdom
Objective: To evaluate the relationship between NHS performance indicators and the average annual expenditure on private medical insurance (PMI) premiums at a national level as well as in different income and age groups, between 1996-2014.
Design: A retrospective study of regional level data using ordinary weighted least squares regression.
Participants: Nationally representative data on PMI expenditure using a sample size of 116,383 households over the period 1996-2014 (obtained from the Office for National Statistics).
Main outcome measures: The impact on expenditure on PMI with a change in NHS performance- namely, a change in the percentage of NHS patients waiting over 18 weeks for treatment, the number of full-time equivalent NHS staff, the number of NHS last-minute cancelled operations and UK government expenditure on health per capita, using multiple linear regressions.
Results: Waiting times were found to be significant and positively related to the average annual household expenditure on PMI. Government expenditure on health per capita was also significant, however, an unexpected positive relationship was observed. Furthermore, staffing levels and cancelled operations were found to be significant and negatively associated with the average expenditure on PMI, notwithstanding, both produced a small coefficient suggesting their influence as determinants for the demand of PMI is marginal. In general, waiting times had the strongest influence on PMI expenditure amongst all income and age groups.
Conclusions: Despite much inconclusiveness amongst previous studies with regards to the effect of waiting times on demand for PMI, waiting times were found to be the strongest driver of demand for PMI in England.
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SESSÃO 3: Oferta e procura de cuidados de saúde
Impact of vertical integration on the readmission of individuals with chronic conditions
Óscar Brito Fernandes1,2, Rui Santana1,3, Sílvia Lopes1,3 1Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisboa, Portugal, 2Centro Hospitalar de Lisboa Central, EPE, Lisboa, Portugal, 3Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisboa, Portugal
AIM: The main aim of this study is to analyse the impact of vertical integration on the readmission rates and risk of readmission of individuals with chronic conditions.
METHODS: A database including administrative data from 1.679.634 inpatient episodes from years 2002-14 was considered. Chronic conditions were identified from all diagnoses coded with International Classification of Diseases – 9th version – Clinical Modifications codes (1:present). The considered outcome was 30-day hospital-wide all-cause unplanned readmission (1:readmitted). Gender, number of Elixhauser comorbidities, and treatment in a vertically integrated unit (LHU) were also included. In order to assess the impact of vertical integration on the readmission of individuals with chronic conditions, we compared 30-day readmissions before and after the creation of each LHU using a difference-in- differences technique.
RESULTS: Difference-in-differences results suggest that vertical integration promoted a decrease on risk-standardized readmission ratio in four LHU, but significant only for one. When analysed the individual risk of readmission we observed that it was reduced for four LHU, but significantly for only two. A sensitivity analysis was performed for annual evolution of odds ratio of risk of readmission, and initial results were considered stable for most years.
CONCLUSIONS: Individuals with chronic conditions faced higher risk of readmission, despite vertical integration phenomena. In order to promote better healthcare to these individuals, healthcare organizations should develop integrated care pathways for the most prevalent chronic conditions on their catchment area, revise discharge processes, evaluate value-based health outcomes, and share best practices of integration involving community and other levels of care.
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Benchmarking nos Cuidados de Saúde Primários na região Centro: o desempenho relativo como mecanismo de competição
Isabel Morais-Henriques1,2, Susana Oliveira1,3, Elvira Silva1,4 1Faculdade de Economia da Universidade do Porto, Porto, Portugal, 2Administração Regional de Saúde do Norte, IP, Porto, Portugal, 3Porto Business School, Porto, Portugal, 4Centro de Economia e Finanças da UP (CEF.UP), Porto, Portugal
O objetivo deste trabalho foi avaliar o desempenho relativo entre unidades de cuidados personalizados da região centro, independentemente do modelo organizativo.
Construímos seis modelos que incluíram a variável qualidade e ajustamento para fatores exógenos e utilizámos o DEA para determinar os rankings de eficiência entre as unidades. Recorrendo a dados de 2015 de 84 unidades (UCSP, USF-A e USF-B) estimámos 24 rankings e 48 scores de eficiência técnica, com utilização da remuneração e do número de profissionais como inputs.
Encontrámos, na totalidade dos 48 scores, 4 unidades eficientes (2 UCSP e 2 USF-A) e 15 ineficientes (7 UCSP, 6 USF-A e 2 USF-B). Os scores de eficiência indicam que as unidades da região Centro podem reduzir entre 25,5% e
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33,5% na remuneração de todos os profissionais, se forem adotadas as condições dos benchmarks, ou aumentar a produção de todos os outputs entre 13,4% e 26,5% com o mesmo número de profissionais.
Os resultados permitem concluir que, em média, as USF-A da região Centro foram mais eficientes e que a remuneração das USF-B foi excessiva. O modelo de incentivos remunerou a tipologia de unidade e não necessariamente os benchmarks. A transformação de todas as unidades em USF-B pode trazer custos significativos para o SNS, principalmente se mantido o modelo de remuneração atual. A pressão competitiva das USF-A para chegar a B e a expectativa de uma remuneração futura podem explicar o melhor desempenho destas unidades, o que pode estar alinhado com mecanismos do tipo da Yardstick Competition.
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The Health Production Function Revisited: The Role of Social Networks and Liquid Wealth
Carolina Santos, Pedro Pita Barros Nova School of Business and Economics, Lisbon, Portugal
Building upon the Grossman model (1972), we propose an extended model of health production, which accounts for the role of social network interactions and share of liquid wealth. By applying a comparative statics analysis we predict that, in face of an event that decreases the efficiency of health production, the optimal response is to increase both the share of liquid wealth as well as social network interactions. The extended model of health production shows the interaction between social networks and the share of liquid wealth on health production to be non-trivial, thereby implying that this is essentially an empirical question. We conjecture that individuals with relatively illiquid wealth and who, therefore, do not have much room to respond to unexpected health expenses or to engage in preventive health-care investments, do instead rely on the support provided by their social networks as an alternative input in the production of health.
To test these hypotheses, and using data from the Survey of Health, Ageing and Retirement in Europe (SHARE), we develop a four-equation recursive system which allows us to control for the potential endogeneity of social networks and the share of liquid wealth in the production of health. The empirical model corroborates the theoretical predictions and shows that, as initially conjectured, social network interactions and the share of liquid wealth are substitutes in the production of health.
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Towards a balance between physicians’ supply and demand, equity of physicians across specialties and cost considerations: Developing a comprehensive tool to assist health workforce training
Marta Monteiro1, Teresa Cardoso-Grilo2,1, Mónica Oliveira1, Ana Barbosa-Póvoa1, Mário Amorim Lopes3 1Centre for Management Studies, Instituto Superior Técnico, Lisbon, Portugal, 2Instituto Universitário de Lisboa (ISCTE-IUL), Lisbon, Portugal, 3INESC-TEC Porto, Faculdade de Engenharia da Universidade do Porto, Porto, Portugal
Appropriate health workforce planning is recognized as critical to ensure health systems’ effectiveness and responsiveness, as well as access of populations to care. Such planning is deemed as relevant for European countries in general, and for Portugal in particular, since imbalances in the availability of health human resources have often translated into efficiency, quality and cost problems. Despite the importance of planning, few tools to assist health workforce planning are reported in literature, and these do not consider the multiple objectives that are pursued by health policy-makers.
This study proposes an optimization-based tool to support the planning of physicians training in the context of NHS-based countries that comprehensively considers health policy-makers objectives and concerns. Departing from mapping stakeholders and their objectives, from structuring the medical training process, as well as from collecting projections on physicians’ supply and demand and from reflecting upon key uncertainties, the proposed tool is designed
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to inform about medical schools’ entries and medical specialty vacancies when multiple objectives pursued by health policy-makers and health system and training constraints are considered. The multiple objectives include minimizing the oversupply and shortages of physicians, maximizing equity in the distribution of physicians across specialties, and minimizing health and educational training costs.
The proposed tool is applied to the Portuguese context and data, showing that substantial adjustments need to be performed both in the numerus clausus from medical schools and in vacancies of medical specialties to anticipate future health system changes.
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Evaluating the Impact of Physicians’ Provision on Primary Healthcare: evidence from Brazil’s More Doctors Program
Luiz Felipe Fontes1, Otavio Canozzi Conceição1, Paulo de Andrade Jacinto2, Mauricio Saraiva3 1Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil, 2Federal University of Paraná, Curitiba, Brazil, 3None, Porto Alegre, Brazil
This study aims to evaluate the More Doctors Program (Programa Mais Médicos PMM), a large scale Brazilian intervention in public health, presenting estimates of its impact on hospitalization for ambulatory care sensitive conditions (ACSH). The differences-in-differences method was used with propensity score matching, using three specifications, a falsification test and also a dynamic endogeneity test to confirm the robustness of the results. For the application of this methodology, a panel of municipal data was constructed covering several variables related to socioeconomic, demographic and public health infrastructure characteristics in the cities for the period from 2010 to 2016. The results show a significant reduction in hospital admissions in treated municipalities with an increasing and perceptible effect already in the first year of the program.
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SESSÃO 4: Equidade e determinantes sociais da saúde
Geographic Variation in Healthcare Expenditure in the Netherlands: Evidence from Movers
Ana Moura1,2, Martin Salm1, Rudy Douven2,3, Minke Remmerswaal2,1 1CentER, Tilburg University, Tilburg, Netherlands, 2CPB Netherlands Bureau for Economic Analysis, Den Haag, Netherlands, 3Erasmus University Rotterdam, Rotterdam, Netherlands
Objectives: Geographic variation in healthcare is well documented for many countries, but its causes have been subject of debate both in the literature as well as among policy-makers during the last decades. We aim at disentangling demand- and supply-driven geographic variation in healthcare expenditure.
Methods: We use proprietary administrative health insurance data covering the entire Dutch population over 8 years, resulting in a panel dataset with above 100 million observations. Following movers over time allows to control for both observed and unobserved patient characteristics. The change in individual healthcare expenditure upon the year of move to a new region is used to infer about the relative importance of demand- and supply-factors as determinants of geographic variation.
Results: Our baseline results point to a supply share of 0.43, suggesting that demand- and supply-side factors explain a roughly equal share of variation. This share varies across distinct categories of care: we find a supply share of 0.76 for dental care, whereas that for hospital or pharmacy expenditure is below 0.3.
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Conclusions: This is work in progress. Preliminary results suggest that demand and supply-side factors are equally important drivers of geographic variation in healthcare expenditures. However, there are specific factors within demand and supply that may be playing a more prominent role in driving variations. Our next step consists on narrowing down the supply side by assessing the importance of physician payment schemes (salary vs. fee-for-service) in explaining regional variations, under the current empirical approach. This would allow to draw some policy implications.
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Making the case for the standardisation of unmet health care needs across Europe
Óscar Lourenço1,2, Micaela Antunes1,2, Carlota Quintal1,2, Luis Mora Ramos1,2 1CeBER, Coimbra, Portugal, 2FEUC, Coimbra, Portugal
Self-reported unmet health care needs have been used to evaluate equity of access. While previous studies estimated unmet need prevalence for the whole population, we claim that the meaningful prevalence should consider only those who actually needed care because is for this population that the health system must respond. Moreover, the socioeconomic characteristics of the population might determine the propensity to recognize unmet needs. Thus, for comparison across countries some standardization (by utilization, sex, education and income) has to be performed.
We used data from European Social Survey (2014) allowing estimating the crude prevalence of unmet need, within the population who needed medical care. To compare prevalence across countries we use one-way analysis-of-variance. In addition, we adopt methods from the epidemiologic literature to obtain direct standardized prevalence estimates.
Both estimates (using all population or population with need) show Netherlands with the lowest prevalence and Poland with the highest, but different increases in prevalence are found (Israel shows an increase of 6 pp above the average).
When standardized for population structure, some countries perform relatively worst (Czech Republic falls 3 positions) and others relatively better (Ireland and Norway increase their relative performance by 2 positions).
Despite the universal coverage provided by European health systems a high prevalence of unmet needs still persists, presenting a high variation across countries. Despite questionnaires focusing on supply side barriers some nuances due to population structure were found; standardizing unmet needs by need provides fairer comparisons across countries.
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Social capital and health deprivation: an exploratory analysis based on ESS data
Micaela Antunes1,2, Óscar Lourenço1,3, Luís Moura Ramos1,2, Carlota Quintal1,3 1Faculty of Economics of the University of Coimbra, Coimbra, Portugal, 2CeBER, Coimbra, Portugal, 3CEISUC, Coimbra, Portugal
Social capital may provide easier access to health information and to health-enhancing goods and services, it may facilitate the provision of informal care and increase the value attached to life, leading to reduced risky behaviours. In previous work we have explored the link between single indicators of social capital (SC) and unmet needs (healthcare deprivation). Here our aim is to move a step forward and assess the link between SC and health deprivation. Moreover, because these concepts are multidimensional, we adopt composite measures for both. Data come from the European Social Survey 2014. Regarding SC we considered variables associated with social/organizational/political participation and trust. Concerning health the variables included were self-assessed health, perceived happiness and life enjoyment and various indicators close to mental health such as depression, feeling lonely, restless. Factor analysis was used in this exploratory approach to generate composite measures of SC and health. In Portugal, SC scores are higher for men and decrease across age groups (18-24; 25-44; 45-64; 65+), ranging from 0.45 to -0.17. We found negative correlations between SC and health deprivation. This association is significant and stronger for the case of social/organizational participation (correlation coefficient = -0.29, which is similar to those obtained for other European countries). Given the many other important predictors for health, such as education and material living conditions, the
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correlations obtained seem relevant. In future research, other methods will be explored as well as further disaggregation of results by groups of individuals and variables.
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Determinantes da prevalência de tempo em frente à TV de adolescentes no Brasil
Cássia Kely Favoretto Costa1, Marina Silva da Cunha1, Olívia Takahashi Margarido2, Flávia Fernanda da Silva Machado2 1Docente do Programa de Pós-Graduação em Ciências Econômicas da Universidade Estadual de Maringá (UEM), Maringá, Brazil, 2Mestranda em Ciências Econômicas da Universidade Estadual de Maringá (UEM), Maringá, Brazil
Este trabalho tem como objetivo associar a prevalência de tempo diário dos adolescentes em frente à TV (superior a 2 horas) com o consumo regular de alimentos não saudáveis, variáveis socioeconômicas e demográficas, dependência administrativa da escola e composição familiar. Para isso foi usada a PeNSE de 2012 e 2015, aplicando-se o modelo econométrico Logit. Em 2012 e 2015, consumir alimentos não saudáveis, ter cor da pele preta ou parda, idade inferior a 13 anos, condição socioeconômica desfavorável, estudar em escola pública, residir com somente um dos pais e nível de escolaridade mais baixo das mães foram as variáveis que tiveram maior impacto na probabilidade de se passar mais de duas horas diárias em frente à TV. Verificou-se que esse hábito diminuiu em 2015 comparado a 2012, entretanto, ainda é recorrente entre os jovens, o que pode influenciar a saúde e qualidade de vida desse público, bem como gerar implicações econômicas para o país.
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Effect of socioeconomic factors on health: a closer look at municipalities
Raquel Duarte1,2,3, Rita Gaio4, Milton Severo5, Alvaro Almeida6 1EpiUnit. Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal, 2Faculdade de Medicina da Universidade do Porto, Porto, Portugal, 3Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal, 4Faculdade de Ciências, Porto, Portugal, 5EpiUnit. Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal, 6Faculdade de Economia, Universidade do Porto, Porto, Portugal
There is currently recognition that several interconnected, socio-economic, environmental and individual aspects contribute to health. We develop a tool that is intended to capture the meaning of health as defined by the WHO and may be used to evaluate the effect of socio-economic factors at the municipality level. From various official sources, we selected all available indicators that satisfied the following criteria: data clearly defined, measurable and verifiable; availability of longitudinal data; relevance; availability at national/district/municipality level. Using principal component analysis we identified two uncorrelated indicators explaining 63% of the observed variance (43% with indicator 1 and 20% with indicator 2). Robustness was verified using Pearson correlation to investigate the degree of association between the developed indicators and each of the three components from the Grossman model (age, education and income). Both indicators had a positive correlation with the percentage of people over 65 years, and a negative correlation with the purchasing power and the percentage of individuals with higher education. The indicators developed are an adequate representation of health status at the municipal level, and are used to estimate the effect of some economic determinants on health.
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Condições econômicas afetam o estilo de vida dos indivíduos? Evidências de microdados para o Brasil
Lívia Madeira Tríaca1,2, Paulo de Andrade Jacinto3, Cesar Augusto Oviedo Tejada4, Marco Túlio Aniceto França2 1Fundação Universidade Federal do Rio Grande, Rio Grande, Brazil, 2Pontificia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil, 3Universidade Federal do Paraná, Curitiba, Brazil, 4Universidade Federal de Pelotas, Pelotas, Brazil
Objetivo: Analisar a relação entre condições macroeconômicas e o estilo de vida individual para o Brasil, no período de 2006-2014.
Método: A análise foi feita através de um painel de dados, formado por cross-sections repetidas de 2006 a 2014, com duas unidades de observação, indivíduos e estados. Os dados a nível individual possuem como fonte Vigitel. Seis medidas de estilos de vida foram analisadas, obesidade, tempo em frente à televisão, tabagismo, consumo de álcool, atividade física e consumo regular de frutas e hortaliças. Para condições macroeconômicas foi utilizada como proxy a taxa de desemprego estadual. Os efeitos da taxa de desemprego sobre os estilos de vida foram estimados através de modelos de mínimos quadrados ordinários com efeitos fixos.
Resultados: A relação entre taxa desemprego e estilos de vida se mostrou significativa para cinco dos seis estilos analisados. Encontramos relação significativa para obesidade, tempo em frente à televisão, tabagismo, consumo de álcool e atividade física. Os resultados demostram que a instabilidade econômica ocasiona uma redução nos comportamentos de risco, como tabagismo, consumo de álcool e obesidade, e em um comportamento saudável, pratica de atividades de físicas, apresentando também um efeito significativo e positivo no tempo em frente à televisão.
Conclusão: Os resultados brasileiros apontam para efeitos distintos de acordo o estilo de vida analisado. Formuladores de políticas públicas devem considera dedicar seus esforços para diminuir os efeitos negativos gerados pela instabilidade econômicas em comportamentos sedentários, como práticas de atividades físicas e o tempo em frente à televisão.
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SESSÃO 5: Hospital economics (English stream)
Towards improved surgical decision-making: A multimethodology to understand variability in surgeons' choice of treatments and to build a decision support model
Liliana Freitas1, Mónica Oliveira1, Teresa Cabral Braga2, João Coutinho2, José Mendes de Almeida3, Carlos Bana e Costa1 1Centro de Estudos de Gestão do Instituto Superior Técnico, Lisboa, Portugal, 2Departamento de Cirurgia, Hospital de Santa Maria, Centro Hospital Lisboa Norte, Lisboa, Portugal, 3Departamento de Cirurgia, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
Surgeons use their expertise, capabilities and guidelines’ knowledge in daily decision-making. Nevertheless, literature in the area points out for large and unexplained variability in surgical decisions, even in areas in which scientific evidence is available. This study aim is twofold: constructing methods to understand variability in surgical decision-making while producing a model to assist surgeons in their choice of treatments. A multimethodology based on the MACBETH multicriteria approach was designed and built with ten surgeons from Hospital de Santa Maria in Lisbon for the context of treating acute cholecystitis in patients with more than 72 hours of symptoms. The multimethodology starts by using exploratory interviews to understand the multiple factors that surgeons consider in the evaluation of patients within a value tree structure. Then, making use of a web-based platform, surgeons judgments are collected and used to build multicriteria models that depict each surgeon decision-making process. Finally, all surgeons participate in a decision conference where a group model is built to evaluate those patients. By applying the multimethodology, we could explore the initial variability across surgeons’ views, the convergence towards a group
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evaluation model, as well as produce a common multicriteria model that can assist surgeons in their future decisions. Results show substantial differences in surgeons’ individual opinions but a large scope for convergence towards a group model. It is relevant to develop further research to test the use of the model by surgeons in their practice, and to test the multimethodology for different contexts.
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Are incentives driving day surgery pratice in Portuguese public hospitals?
Sílvia Sousa1,2, Paula Veiga1,3 1Universidade do Minho, Braga, Portugal, 2NIPE, Braga, Portugal, 3NIMA, Braga, Portugal
Ambulatory surgery is a cost-saving technological and organizational innovation. The literature suggests ambulatory surgeries are cost-effective, contribute to reduce the waiting time and increases the hospitals’ productivity. These are critical aspects for the Portuguese health care system facing several challenges among which severe financial cuts.
Day surgery has gained increasing significance in the Portuguese health care over the last years, representing, in 2014, 71% of non-emergency surgeries (IASIST, 2015) Nonetheless, there are still significant differences among regions and hospitals. Moreover, the data also suggests some variation within hospitals among specialities and across time.
The aim of this paper is to explain the diffusion and the observed variations in ambulatory surgery rates among Portuguese hospitals. Using data from the National Survey on Ambulatory Surgery published by the Portuguese Association on Ambulatory Surgery (APCA) combined with data from the Portuguese Ministry of Health, we estimate a regression model using fractional logit techniques, covering a period of around a decade.
Based on the results (still preliminary) the paper discusses the role of organizational factors and economic incentives on adoption and diffusion of one day surgery.
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AN INSIDE LOOK INTO HAIs: Resources And Strategies In Health Organizations
Sandra Oliveira1, Sofia Ferreirinha2, Hugo Sousa3, Carla Cordeiro2, Ana Tavares2, Claudia Simão2 1IPSantarém, Santarém, Portugal, 2Hospital Distrital de Santarém, EPE, Santarém, Portugal, 3USF D. Sancho I - ACES Lezíria, Santarém, Portugal
In Portugal, we estimate that 5 in 100 patients could have acquired Healthcare Associated Infections (HAIs) during hospitalization (OPSS, 2015). Research for organizational solutions that could contribute to reducing the prevalence rate and cost of HAIs is much needed. Our aim is to develop and validate an instrument that allows: 1) Identify good practices implemented to control HAIs based on standard precautions, 2) To verify the applicability of the legal norm n.029/2012-BPIC from the Directorate-General Health (DGH).
We will carry out three studies, that are somehow interrelated. In the first one we developed a pool of items to be used in the questionnaire based on the legal norm from DGH. In the second, a focus group was held to encourage participants to exchange experiences and opinions about the questions generated and refine the survey. The third is ongoing and it consists in using the final questionnaire in seven hospitals, in surgery and medicine service, from Portugal.
The content of questionnaire resulted from the combination, reflection and informal conversations with experts, the DGH practice regarding standard precautions and outputs from the Focus Group. The results from the third study is a work in progress, we already applied the questionnaire and handle some data.
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This research sought mainly to develop and validate an instrument for: measuring hospital workers’ attitudes toward the legal norm and identify the best organizational practices that will allow us to assess the importance of the organizational dimension in the contest HAIs. To our knowledge, any previous instrument took into account the organizational dimension.
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Desperately searching high users of hospital emergency services
Inês Catarino1, Pedro Pita Barros2 1Faculdade de Ciências e Tecnologia - Universidade Nova de Lisboa, Lisboa, Portugal, 2Nova School of Business and Economics, Lisboa, Portugal
Portuguese Emergency Departments (ED) are faced with the challenges of overcrowding and waiting times on a daily basis. The very high number of ED visits often results in excessive resource consumption, decreased quality of care and efficiency. To understand what causes this disproportionately, there is a need to identify and create a profile of the patients who frequently use the ED, in order to clarify the impact of a number of factors in this problem. This study uses a patient database covering all hospital admissions in Portugal in 2015. We determined the proportion of emergency department users that make 4 or more visits in the same year. A probit model will be estimated to evaluate the importance of different factors, such as having a family doctor and/or chronic diseases, in the number of ED visits. Preliminary results indicate that approximately 10% of total ED patients are frequent users and that age does not have a great impact in the results. They also show that a considerable number of frequent patients do not have a family doctor and have one or more chronic diseases. The combination of these factors suggests that frequent emergency department users are a vulnerable group of patients, more likely to have diseases. Case management is one solution that can provide special orientation for these patients. Targeting of policies seems adequate to address this issue.
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Time trend of avoidable hospitalization and their related charges in Portugal
João Vasco Santos1,2, Júlio Souza1,2, Manuel Gonçalves-Pinho1,2, João Viana1,2, Alberto Freitas1,2 1Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, 2CINTESIS – Center for Health Technology and Services Research, Porto, Portugal
BACKGROUND/GOALS: Primary care is a cornerstone of the Portuguese National Health System and its quality can be evaluated, for example, by means of the avoidable hospitalizations. In this line, the prevention quality indicators (PQIs) are a tool to assess them. As time trends of performance of healthcare services are a major input in healthcare decision making, our aim was to describe the time trend of PQIs in Portugal and their economic burden.
METHODS: We performed a retrospective study, analyzing all mainland Portuguese hospitalizations in adults between 2011 and 2015. We considered only the overall composite PQI (PQI 90). We calculated charges in Euros, according to the expenditure tables (reimbursement) for Portuguese National Health Service hospital costs, which were defined by governmental regulation, from different 3MTM All-Patient Diagnosis-Related Group (DRG) versions (i.e. 21, 27 and 31 from tables of 2009, 2013 and 2015, respectively).
RESULTS: Of all the hospitalizations occurred between 2011 and 2015, 407,792 hospitalizations were included in the PQIs. There was an increase in the number of avoidable hospitalizations from 74,589 in 2011 to 86,762 in 2015. However, as the average charge decreased 584 Euros in this period, the total reimbursed charges decreased almost 17 million Euros.
CONCLUSIONS: Although increased number of cases of avoidable hospitalizations, the total charges decreased due to a lower reimbursed average charge per hospitalization. Thus, primary care quality, though being possibly
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decreasing, is leading to hospitalizations with lower reimbursed charges which can have an important economic impact in hospital care.
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SESSÃO 6: Medição de resultados em saúde
Overcoming common critical mistakes in building population health indices through the MACBETH socio-technical approach
Vieira Ana1, Mónica D. Oliveira1, Teresa Rodrigues1, João Bana e Costa2, Ângela Freitas3, Liliana Freitas1, Paula Santana3, Carlos Bana e Costa1 1CEG-IST, Centre for Management Studies of Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal, 2Bana Consulting LDA., Lisboa, Portugal, 3Centre for Studies in Geography and Territorial Planning, Faculdade de Letras, University of Coimbra, Coimbra, Portugal
Monitoring the health status of a population helps detecting emerging patterns of illness and disease, and provides valuable information to drive health related policies and the planning of health services. Formal assessment tools, such as population health indices (PHI), which aggregate multiple population health indicators, are often built with ad hoc processes and suffer from theoretical meaningfulness. In this presentation, we show how common critical mistakes in developing a PHI can be avoided by following the principles of multi-criteria value modelling. Specifically we describe how the MACBETH socio-technical approach has been devised to overcome these problems and to assist population health indices construction in the context of the EURO-HEALTHY H2020 and of the GeohealthS FCT projects. Under this technical framework, the added value to health of improving performance on a criterion is measured by a value-function (or by a conditional value-function in case of interdependencies) and the relative importance of performance improvements in different criteria is measured by relative weights. The judgemental information to define value-functions and weights can be elicited with MACBETH through two-stage participatory processes: a Delphi panel with a large number of experts and stakeholders to agree upon value-functions shapes and “qualitative” weights, which then informs a decision conferencing process with a small strategic group. We describe how this approach was successfully applied to build indices at the municipality level in Portugal and at the regional level in Europe, enabling to investigate health geographic inequalities and to identify where there is higher need for health policy intervention.
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Controlo de qualidade dos dados na valoração portuguesa do EQ-5D-5L
Patricia Antunes1,2, Pedro Ferreira1,3, Lara Ferreira1,4 1CEISUC, Coimbra, Portugal, 2ARSC, Coimbra, Portugal, 3FEUC, Coimbra, Portugal, 4ESGHT-Universidade do Algarve, Faro, Portugal
Contextualização: Estudos prévios de valoração da nova versão do EQ-5D, o EQ-5D-5L, evidenciaram consequências indesejadas na qualidade dos dados, resultantes do efeito causado pelo desempenho dos entrevistadores. Neste âmbito, o grupo EuroQol criou um processo padronizado de controlo de qualidade, para aplicação nos estudos de valoração que utilizam as técnicas de compromisso de tempo compósito (cTTO) e experiência de escolha discreta (DCE), com o objetivo de monitorizar o desempenho dos entrevistadores e a qualidade dos dados obtidos.
Objetivos: Descrever o processo de controlo de qualidade seguido no estudo português de valoração do EQ-5D-5L e apresentar os resultados obtidos no âmbito da qualidade dos dados.
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Métodos: Foi utilizada a ferramenta QC Tool que permitiu monitorizar o desempenho dos entrevistadores, com recurso a estatísticas descritivas e à avaliação do cumprimento de critérios pré-definidos de qualidade.
Resultados: Dos 39 entrevistadores que iniciaram a recolha de dados, 28 cumpriram os critérios de qualidade obtendo 9% de entrevistas assinaladas no total de 1.451 entrevistas realizadas. De uma forma geral, os entrevistadores cumpriram as etapas previstas nos estados de valoração de treino o que permitiu a obtenção de dados com maior qualidade nas tarefas reais de valoração, traduzidos por um número reduzido de participantes com inconsistências, ausência de picos em torno de valores específicos e existência de valorações piores que morte (negativas).
Conclusões: A implementação de um processo de controlo de qualidade nos estudos de valoração do EQ-5D-5L aumenta a adesão do entrevistador ao protocolo estabelecido e a qualidade dos dados obtidos.
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Estimation of the EQ-5D-5L value set for Portugal
Pedro Ferreira1, Lara Ferreira2, Luís Pereira3, Patrícia Antunes4 1CEISUC/FEUC, Coimbra, Portugal, 2CEISUC/UALG, Faro, Portugal, 3UALG/CEIO, Faro, Portugal, 4CEISUC, Coimbra, Portugal
Background: The EQ-5D-3L has five dimensions each with three levels of impairment. Previous research showed that the EQ-5D-3L may not fully discriminate different levels of health status among individuals. To improve its discriminatory power, the EuroQol Group has recently expanded this instrument by adding two intermediate levels (EQ-5D-5L).
Objective: The purpose of this study was to elicit EQ-5D-5L health states preferences from the general Portuguese population and to estimate the Portuguese value set to assign values to all the EQ-5D-5L health states.
Methods: A representative sample of the Portuguese general population was stratified by age and gender. Twenty-eight interviewers performed CAPI interviews which included two valuation techniques: the composite time trade-off (cTTO) and a discrete choice experiment (DCE). To model cTTO data we used OLS and random-effects GLS models and tobit random effects models censoring at -1. We also modeled DCE data by logit and probit models. A basic main effects hybrid model estimated data together from both TTO and DCE parts. All models were compared in terms of goodness of fit statistics and prediction ability.
Results: A sample of 1,451 inhabitants revealed a smaller ceiling effect than experienced in the 3L version and the respondents showed a VAS mean score of 78.9 in a 0-100 scale. All cTTO and DCE models showed no inconsistencies and all hybrid model coefficients were consistent.
Conclusion: This research provided the Portuguese value set for the EQ-5D-5L on the basis of cTTO and DCE. These results are recommended for the use in CUA to be conducted in Portugal.
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MEDIÇÃO DA QUALIDADE DE VIDA RELACIONADA COM A SAÚDE EM DOENTES COM PSORÍASE-RESULTADOS DO ESTUDO PESSOA EM COMPARAÇÃO COM POPULAÇÃO PORTUGUESA
Ines Moital1, Lara Noronha Ferreira2,3, Sofia Oliveira-Martins4, Pedro Laires1, José Cabrita4 1HE&OR Novartis Farma, Porto Salvo, Portugal, 2Universidade do Algarve-ESGHT, Faro, Portugal, 3Centro de Estudos e Investigação em Saúde da Universidade de Coimbra (CEISUC), Coimbra, Portugal, 4Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal
OBJETIVOS: Medir a qualidade de vida relacionada com a saúde (QVRS) em doentes com psoríase (PsO) e comparar com a população geral portuguesa. Também visa explorar as associações entre a QVRS e as variáveis sociodemográficas.
MÉTODOS: Os dados provêm do estudo PeSsoA: um estudo transversal em doentes com PsO, que inquiriu uma amostra de doentes com pelo menos 18 anos (n=564). Foi aplicado um questionário (Jun-Jul2016) que incluiu o EQ-5D-3L, o Índice de Qualidade de Vida da Dermatologia, caracterização socio-demografia e clínica, comportamentos de saúde, impacto social relacionado a PsO e utilização de recursos de saúde. Utilizaram-se medidas de estatística descritiva para descrever a QVRS de doentes psoriáticos e testes paramétricos para comparar a QVRS de doentes com diferentes tipos de PsO. Foram realizadas comparações com dados normativos da população portuguesa. Identificaram-se fatores associados à QVRS usando modelos de regressão.
RESULTADOS: O impacto da doença foi observado principalmente nas dimensões dor/desconforto e ansiedade/depressão. A intensidade dos problemas é significativamente mais evidente nos doentes com artrite psoriática e PsO em placas. A QVRS dos doentes com PsO está relacionada com variáveis sociodemográficas e é menor (médiaEQ-5D-3L=0,75) do que a da população portuguesa (médiaEQ-5D-3L=0,77). Os doentes com artrite psoriática têm uma QVRS inferior (médiaEQ-5D-3L=0,62) do que outros doentes psoriáticos.
CONCLUSÕES: Ter PsO tem um impacto significativo na QVRS global, com maior incidência na dor/desconforto e na ansiedade/depressão. Esses resultados mostram a importância de usar instrumentos de QVRS de forma rotineira em estudos populacionais ou em contextos clínicos.
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Tackling network meta-analysis methodological challenges: a case study on biologic treatments for moderate to severe plaque psoriasis in children and young people
Pedro Saramago, Ana Duarte, Stephen Palmer, Claire Rothery Centre for Health Economics - University of York, York, United Kingdom
Objective: Network meta-analysis (NMA) methods extend the pair-wise meta-analysis framework by allowing the simultaneous synthesis of evidence on more than two interventions. Often the evidence base produces networks that are disconnected, such that there is neither direct nor indirect evidence to compare all relevant treatments. Even when a fully connected network exists, the evidence base may present cross-trial variation in the reference-arm outcomes, which, if not controlled for, may generate biased treatment effect estimates. These challenges are addressed using a case study on the biologic treatments for moderate to severe plaque psoriasis in children/young people.
Methods: A series of Bayesian NMA models were developed. Synthesis models which used external evidence to connect the network in the children/young person population were used. Further model extensions were performed to adjust for population and cross-trial differences. Bayesian measures of fit and adequacy were used to compare and select models.
Results: There were only 3 trials in children/young people in psoriasis, which formed a disconnected network for the four biological treatments. External evidence from an adult population was used to bridge the evidence gap. Reference-arm response rates were identified as a key source of heterogeneity. NMA models adjusted for population and cross-trial differences provided an appropriate method to estimate relative treatment effects for all relevant treatments in children/young people.
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Conclusions: Provided that valid external information can be inserted into the network, methodological approaches to NMA offer the opportunity to derive reliable estimates of relative treatment effects, while adjusting for key sources of heterogeneity.
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SESSÃO 7: Economia hospitalar
Doctors' Response to Queues: Evidence from Portuguese Emergency Rooms
Bruno Martins1, Luís Filipe2 1Boston University, Boston, USA, 2Nova School of Business and Economics, Lisbon, Portugal
The decision of a patient to go to the emergency room creates an externality to other patients as it decreases the amount of resources available at a given point in time. Doctors are forced to ration their time and treatments, which may have consequences for health outcomes. In this paper, we evaluate how doctors respond to the number of patients waiting to be treated in the emergency room in the context of Portuguese hospitals. We study both the overall time spent in an emergency room visit and the intensity of treatment (using the cost of the visit as a proxy for prescription of lab exams and tests). Using admission level data for 2011 and 2012 in one hospital in the Lisbon area, we use a fixed effects model to exploit variation in the number of admissions within an hour. We estimate doctors’ reactions separately for patients with different severity, as measured by the manchester triage system. Results show that doctors discharge patients more rapidly as queues become longer, and this effect is stronger for patients that do not have life-threatening conditions. We also find that doctors prescribe less treatment (exams and lab tests) when patients face longer queues. This effect is also larger for patients without life-threatening conditions. Our results imply that doctors’ behavior prevents queues and waiting times to be longer than the observed ones and, moreover, they ration patients efficiently.
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Overestimation of health urgency as a cause for emergency services inappropriate use: an exploratory economics experiment
Anabela Botelho1,2, Correia Isabel3,4, Fernandes Tania5, Pinto Ligia3,5, Teixeira Jorge6, Valente Marieta3,5, Veiga Paula3,5 1DEGEIT, Universitdade de Aveiro, Aveiro, Portugal, 2GOVCOPP, Universidade de Aveiro, Aveiro, Portugal, 3EEG, Universidade do Minho, Braga, Portugal, 4NIma, Universidade do Minho, Braga, Portugal, 5NIMA, Universidade do Minho, Braga, Portugal, 6Hospital de Braga, Braga, Portugal
This paper analyses whether a misperception of symptoms’ severity of the condition by patients can help explain inappropriate use of hospitals’ emergency departments by non-urgent patients. We implement in an incentivized manner an exploratory economics experiment to elicit the degree of severity of five sets of symptoms. We ask participants to indicate the more suitable health service for each set of symptoms, before and after revealing the true degree of severity. Results show that there is an overestimation of the degree of severity of some clinical profiles, and when confronted with the real severity of those clinical profiles, in only half of the cases is the choice changed to other health services. Although exploratory, this study provides insights into the role that the misperception of symptoms severity plays in explaining emergency department inappropriate use and, at the same time, the potential limits of a policy focusing on this factor.
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Understanding avoidable caesarean sections: Are hospital characteristics important?
Ceu Mateus1, Carla Nunes2 1Lancaster University, Lancaster, United Kingdom, 2UNL Escola Nacional de Saúde Pública, Lisbon, Portugal
C-section rates have been high above the WHO threshold (15%) in Portuguese NHS hospitals. There are clinical implications concerning the overuse of this procedure not to mention the costly implications it presents in financially strained health care systems. Annual data for the period 2002-2009, covering all NHS hospitals, C-section ICD-9-CM codes considered were 74.0-74.2 (Classical, low cervical or extraperitoneal caesarean), 74.4 (Caesarean section of other specified type) and 74.99 (Other caesarean section of unspecified type). Hospital characteristics are hospital’s size (total number of beds, as a proxy) and specific gynecology-obstetrics (GYNOB) resources assessed with three ratios, and availability of neonatal UCI. Descriptive statistics were used and binary logistic regressions were computed based on enter (to compute crude odds ratios) and forward variable selection methods (final models for both event under study). Based on a multivariate approach, high incidence areas had human resources and hospital size as significant when in low classes. For areas of high increasing treands, based on a multivariate approach, human resources and hospital size were significant being high classes associate with HIT. It is in the hospitals where more avoidable C-sections are performed and where their rates are increasing more that human resources and hospital size are key variables to understand the trends. Hospital characteristics prove to be important to understand the trends found in Portugal. These results support policies on c-section rates reduction that focus on the continuous training of doctors and peer reviews tailored to specific hospitals.
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Volume-outcome effect, learning-by-doing e economias de Escala no setor hospitalar brasileiro: o caso da artroplastia de quadril (Rip Replacement)
Pedro Henrique Soares Leivas1, Paulo de Andrade Jacinto2, Anderson Moreira Aristides dos Santos3, César Augusto Oviedo Tejada4 1PUC/RS, Porto Alegre, Brazil, 2UFPR, Curitiba, Brazil, 3UFAL, Maceió, Brazil, 4UFPEL, Pelotas, Brazil
Objetivo (Objective): avaliar o volume-outcome effect no setor hospitalar brasileiro para o procedimento de artroplastia de quadril (rip replacement).
Metodologia (Methodology): Os dados utilizados são provenientes do Sistema de Informações Hospitalares e do Cadastro Nacional de Estabelecimentos de Saúde, do Sistema Único de Saúde e compreendem o período de 2008 a 2014. O outcome dos pacientes foi avaliado pela mortalidade intra-hospitalar. Os controles compreendem características dos pacientes, dos hospitais e dos municípios onde os pacientes residem. Para contornar a endogeneidade do volume, empregamos um ivprobit, em que o mesmo foi instrumentalizado por duas variáveis construídas explorando a distribuição geográfica dos pacientes e dos hospitais, a saber: 1) o número de pacientes num raio de 0 a 10 quilômetros do hospital, e 2) o número de hospitais num raio de 0 a 30 quilômetros do hospital. Para investigar se o volume-outcome effect é resultado de economias estáticas de escala ou do processo de learning-by-doing, o modelo acomodou o volume em nível e defasado.
Resultados (Results): Os resultados evidenciam que o volume-outcome effect no Brasil para o procedimento de artroplastia de quadril é resultado da hipótese de practice-makes-perfect e ocorre por meio de ganhos estáticos de escala.
Conclusões (Conclusions): Considerando as evidências de um volume-outcome effect resultado de ganhos estáticos de escala, o estabelecimento de um volume mínimo poderia ser benéfico no sentido de melhorar os resultados de saúde dos pacientes.
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SESSÃO 8: Assessing changes and trends (English stream)
Changes in access to primary care and its socioeconomic patterning in Europe, 2007-2012
Klára Dimitrovová1, Julian Perelman2,1 1Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal, 2Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal
Background: The strengthening of primary care (PC) has been encouraged as a strategy to achieve more efficient and equitable health systems. However, the Great Recession may have reduced the access to PC. This paper aims at analyzing the change in access to PC and its patterning in 28 European countries, between 2007 and 2012.
Methods: We used data from the 2007 and 2012 waves of the EU-SILC questionnaire (n=660,791). The dependent variable was the self-reported access to PC (“easy” versus “difficult”). The change across time was measured using a year binary variable. We modeled the access to PC as function of the year, and individual and country-level variables, using a mixed effects logistic regression, adjusting for sex, age, chronic condition, and self-reported health. Additionally, we interacted the year with socioeconomic and country-level variables.
Results: The probability of reporting difficult access to PC services was 4% lower in 2012, in comparison with 2007 (OR=0.96,p<0.01). People with the lowest educational level (OR=1.63,p<0.01), high difficulty to make ends meet (OR=1.91,p<0.01), with material deprivation (OR=1.24,p<0.01) experienced a significantly higher likelihood of difficult access. The better access in 2012 was significantly higher in people living in countries with higher health expenditures, higher number of GPs, and with stronger gatekeeping.
Conclusions: Our study shows that people with a lower SE status reported worse access to PC. However, between 2007 and 2012, access to PC improved, and this improvement was greater in the countries with a higher investment in health and PC.
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Developing models for improving efficiency and access and for reducing costs in the operating room
Inês Marques1, M. Eugénia Captivo2, Mónica Oliveira1, Ana Barbosa-Póvoa1, Nuno Ramos1 1CEG-IST, Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal, 2CMAF-CIO, Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal
Aims: Surgical activity generates a high portion of hospitals’ funding, has substantial impacts in other areas of hospital provision, and is a social concern for which populations are quite sensitive. Despite several studies showing the scope for increasing operating room (OR) efficiency and reducing costs while promoting access to care, the use of proper tools to systematically search for improvements in OR activity is uncommon in practical settings. Available tools are technically oriented and do not consider the perspectives and views of OR stakeholders. This study develops tools to fill this gap.
Methods: This study combines qualitative structuring approaches with optimization methods to build decision support models to assist resource capacity planning decisions in the OR. Qualitative structuring approaches – based on interviews and problem structuring methods and multicriteria evaluation – are used to capture stakeholders’ views and preferences regarding surgical processes, which are then incorporated into multi-objective optimization models. Such optimization models consider the complexity of OR activity, namely their high variety of specialized medical staff, equipment and material, and their interrelated processes affected by variability.
Results: These methods were applied in a Portuguese hospital, showing the relevance of considering stakeholders’ knowledge and satisfaction within optimization models. The space for improving OR in line with improving efficiency
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as measured by productivity, with improving access measured by waiting times, with decreasing costs, and with improving stakeholders’ satisfaction is shown.
Conclusion: The use of these tools in the OR has a high potential to save hospital costs.
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Health Expenditure and Economic Growth: A Panel Vector Error Correction model for 25 OECD European countries
Joana Cima Faculdade de Economia da Universidade do Porto, Porto, Portugal
This study analyses the dynamics between Gross Domestic Product and Health Expenditure for 25 OECD European countries from 1995 to 2015. Noting that there is comprehensive and recent literature about the impact of the economic recession on the health status, we intend to understand whether a possible deterioration in health was a result of a significant contraction in the health expenditure growth in the last years.
A Panel Vector Error Correction model with country fixed effects is estimated since both time series are integrated of order 1 and after finding a long-run relationship between them. We also include time dummies to assess how the dynamics of growth was changed during the economic crisis of 2007/2008 as well as during the economic recovery of 2013/2014.
The results indicate that the recession contributed to a significant fall in the GDP growth. After the “end” of the recession, estimates suggest that economic growth has not yet reached the pre-crisis growth levels. A noteworthy result is found in the health expenditure growth. Despite health expenditures being shown to decline during the recession, when controlling for country fixed effects, it is expressed that in a time of crisis they did not change significantly from the pre-crisis growth levels.
For a better understanding of health expenditure growth, extra estimates should be performed to see how it reacts to specific shocks in demand and supply. We also seek to identify how the different dynamics vary, when considering specific measures of the country and health system heterogeneity.
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An innovative payment model for the Portuguese mental health system
Julian Perelman1,2, Maria Ana Matias3 1Centro de Investigação em Saúde Pública, Lisboa, Portugal, 2Escola Nacional de Saúde Pública,, Lisboa, Portugal, 3Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisboa, Portugal
Background: To promote an effective mental health (MH) system, the World Health Organisation has pointed out several recommendations, namely, a larger involvement of primary care settings (PCS) and community-based care for serious mental illnesses (SMI). Portugal is failing to achieve such recommendations. We argue that this is due to an inadequate financing mechanism of MH providers. This study designs a new financing model for MH providers in Portugal.
Methods: We perform a comprehensive review of healthcare providers’ payment schemes and incentives. We review the best practices in MH prevention and care.
Results: We design a four-dimensions model, focusing on the prevention of MH disorders in early life; detection of MH disorders in childhood and adolescence; implementation of a collaborative stepped care model for depression; and a value-based integrated payment for SMI.
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To incentivize the follow-up of children at risk early in life, we recommend a fixed annual amount for PCS. For early detection of MH disorders, we propose an indicator for PCS, number of users aged 18 or below attended to check-up consultations.
Regarding depression, we propose that each PCS should have a reference GP for MH and a specialist who provides consulting. The GP and psychiatrist should receive a monthly fixed fee.
To treat SMI, we propose the implementation of an annual payment per patient based on diagnosis.
Discussion: By implementing this MH financing plan, we expect that the system will incentivize early prevention and detection of MH disorders, higher access to MH care, and integrated care for SMI.
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SESSÃO 9: Custos em saúde
Custo do tratamento do cancro em Portugal
José Machado Lopes1, Francisco Rocha Gonçalves1, Marina Borges1,2, Patrícia Redondo1, José Laranja-Pontes1 1IPO Porto, Porto, Portugal, 2Estudante de Doutoramento na ENSP – Universidade Nova de Lisboa, Lisboa, Portugal
Introdução:O cancro é a segunda causa de morte em Portugal, com 24,3% de óbitos por tumores malignos.Os efeitos económicos do cancro tornam-no uma prioridade devido ao forte impacto na perda de produtividade e ao aumento dos custos de tratamento.É premente a análise dos custos das doenças oncológicas, para possibilitar conhecer, comparar e controlar custos promovendo a transparência do sistema de saúde.Pretende-se com este estudo estimar a carga económica associada ao tratamento do cancro em Portugal através do apuramento dos custos médicos diretos.
Materiais e métodos:Efectuou-se um estudo baseado na prevalência.A abordagem utilizada para estimar os custos é “top-down” e utilizam-se técnicas de “gross costing”.De modo a se identificarem, quantificarem e valorizarem todos os custos associados ao tratamento do cancro, recorreu-se a várias fontes de dados para obter a informação mais atualizada para os cuidados hospitalares.Criou-se um Painel Delphi modificado para obter os dados relativos aos cuidados de saúde primários.
Resultados:O custo anual de tratamento do cancro em Portugal ascende a 867 milhões de euros, representando 5,5% da despesa total em saúde e 84 € per capita.A principal componente deste custo são os medicamentos antineoplásicos com uma quota de 31,5%.
Discussão e Conclusão:Comparando os custos apurados neste estudo, com o único estudo português realizado em 2009 e com o estudo europeu realizado em 2013, verifica-se um aumento de cerca de 300 milhões de euros no custo anual de tratamento do cancro.O aumento da incidência e o aumento dos custos com medicamentos será uma explicação para esta diferença.
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Comparison of healthcare costs between an implemented Integrated Diabetes Care unit and the traditional National Health System.
Rogério Ribeiro1,2, Alejandra Guillén3, Luis Gardete Correia2, José Manuel Boavida2, Jorge Posada3, João Filipe Raposo2 1Departamento de Ciências Médicas - Universidade de Aveiro, Aveiro, Portugal, 2APDP, Lisboa, Portugal, 3Integrated Health Solutions, Medtronic Iberica, Madrid, Spain
Type 1 and type 2 diabetes are chronic conditions that generate a considerable health and social burden. Integrated care has been seen as beneficial to achieve better diabetes control and prevention of complications. However, this strategy is generally confronted by the traditional organization of dispersed speciality services.
A diabetes outpatient clinic, managed by a non-profit patient association, has designed a series of integrated care pathways. This has been enhanced by educational services tailored to the patients’ needs.
The aim of this research was to assess the value of the implemented integrated care model, depicting a map of the costs associated to the treatment of different groups of patients. A comparative study of the costs was done: of those incurred in this model by 8354 patients (1078 T1D and 7276 T2D) during 2012 versus the ones that the Portuguese National Health Service (PNHS) would have incurred with standard care.
This analysis was performed using a segmentation model. Data was extracted from electronic health records, and from group interviews with professionals. The process was replicated for the PNHS through information obtained from the “Analytical Elements Database, ACSS, 2009”.
Consultation costs were found to be 21% lower for T1D and 38% lower for T2D patients in the integrated model clinic than the same services provided in the PNHS. This is explained mainly by delayed diabetes complications.
This highlights the need for more detail into segmentation of patient needs, to better adapt healthcare services but also to allow the estimation of financial impact.
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Treatment Cost of Serious Mental Illnesses in Portugal
Maria Ana Matias1, Julian Perelman2,1 1Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisboa, Portugal, 2Centro de Investigação em Saúde Pública, Lisboa, Portugal
Background: The Portuguese mental health (MH) system has been relying heavily on hospital care to treat patients with serious mental illnesses (SMI), with a high rate of emergency visits and hospitalizations. Despite best practices recommending integrated community-based care for SMI, the current financing system is highly activity-oriented. A new financing model was proposed, based on a per-period risk-adjusted payment, expected to favor best practices in MH. This study estimates the direct treatment costs of SMI in the Portuguese NHS.
Methods: Data were collected from three public hospitals located in Lisbon and Oporto. It includes all patients with SMI followed during one year (n=3,131). We gathered information on all medical resources and diagnoses using the ICD-9 MH codes. Resources were valued using official tariffs. We assessed the main drivers of the treatment costs using generalized linear models.
Results: Schizophrenic psychosis and delirium illnesses had the highest average cost per patient of 1,577€ and 1,493€, respectively. The cost per diagnosis decreased with age but was higher for patients treated for less than 3 years.
Discussion: The treatment cost of SMI in its acute phase is relatively low in comparison with other chronic diseases. Little has been written on this topic so that there are no international values for comparison. Since community care plays an important role on the treatment of SMI patients, performing an international comparison on the treatment costs between Portugal and countries with a developed community-based care could bring insights on the impact of community care on treatment costs.
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Hospitalized patients with schizophrenia in Portugal: clinical characterization and costs
Francesca Fiorentino1, Raquel Ascenção1, Miguel Gouveia2, João Pascoal3, João Costa4, Margarida Borges1 1Center for Evidence Based Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal, 2Catolica Lisbon School of Business and Economics, Lisbon, Portugal, 3Centro Hospitalar Lisboa Central, Lisbon, Portugal, 4Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
OBJECTIVE: To determine the clinical and demographic characteristics of adult patients hospitalized with schizophrenia in Portugal and to estimate the costs of these hospitalizations.
METHODS: We analyzed the Diagnosis-Related Group (DRGs) database which includes information regarding patients discharged from NHS hospitals in Portugal for the period 2012-2014. Patients who had at least one episode with a principal diagnosis of schizophrenia (ICD-9: 295.xx) were identified and studied. The comorbidity distribution of schizophrenic patients was compared to that of a control group of patients with same age and sex distribution. The controls were randomly selected using a nearest-neighbor matching method. Unit costs were based on national legislation.
RESULTS: On average, 2,586 patients per year were hospitalized. The median age was 41 and 67% were men. The mean (±s.d.) length of stay was 26±58 days when excluding the episodes with transfers to other institutions (10% of the total). 22% of the patients had two or more episodes. When re-hospitalized the probability of changing the classification of the specific type of schizophrenia was 41%. The main comorbidity was substance abuse/dependency and it was found in 24% of the patients, a rate significantly higher than in the control group. 17% were admitted under legal circumstances. The median hospitalization cost per episode was €2,858, with an average annual aggregate cost associated to hospitalization with schizophrenia of €14.6 million.
CONCLUSIONS: Hospitalized schizophrenic patients are mostly young males and a significant proportion is re-hospitalized during the same year.
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SESSÃO 10: Sector do medicamento
Brand authenticity and health care: does it apply?
Pedro Barros1, João Marques Gomes2 1Nova School of Business and Economics, LIsboa, Portugal, 2Nova School of Business and Economics, Lisboa, Portugal
The concept of brand authenticity has been introduced recently in the consumer behavior literature. It considers dimensions such as credibility and integrity, among others. These notions seem to find a field of application in health care services and products. In particular, these concepts may have a role to play in the decisions to acquire over-the-counter pharmaceutical products.
Using a recent survey on the use of health service, we provide a first assessment on people’s perception regarding authenticity of 5 commonly used products (Clavamox, Aspirina, Ben-U-Ron, Plavix and Anginova). When people know the brand, usually a high degree of authenticity is attributed. Recognition varies considerably across products. Authenticity assessments are linked to long presence in the market, with little advantage from being first in arrival to the market, and to performance-as-announced. The way authenticity assessments are made by the population has no general systematic relation with observable characteristics (as measured by application of a probit model).
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A higher preference for generic substitution is positively associated (in a probit model) with having long presence in the market and performance-as-announced as drivers of authenticity. Thus, this marketing notion, although apparently present at the eyes of users of pharmaceutical products, does not seem to provide a significant advantage to brand products over generics.
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Political factors and pharmaceutical markets regulations in OECD countries
Sónia Queirós1, Maria de Lurdes Martins2, Michael Baum1 1ISCTE, Lisboa, Portugal, 2EEG-UM, Braga, Portugal
Health policies have an extensive impact on citizens’ welfare and on the economy. Among others, politicians have the power to: change the health insurance system, subsidize hospitals, regulate the pharmaceutical market and these policies in turn are affected by political factors such as levels of democracy, distribution of power, quality of government or absence of corruption (Mackenbach and McKee, 2015).
In this study we want to examine the political environments that play a role in pharmaceutical markets regulations design and implementation. We want to test empirically whether political factors may explain pharmaceutical markets regulations, giving special attention to the provision and financing of pharmaceutical services in OECD countries. Political cycles, ideology, institutions, quality of government among others are tested as determiners of these health regulations processes and outcome indicators.
The Quality of Government Dataset (QoG) and Comparative Political Dataset (CPDS) are used to extract information on political factors. Health policies data come from European Observatory on Health Systems and Policies series, OECD Reviews of Health Systems; OECD Health Data and International Financial Statistics. In order to study the associations between political environments and pharmaceutical markets regulations’ indicators we perform a series of multivariate linear least squares regression analyses with indicators of health policies as dependent variables.
Literature has been pointing out a strong association between public health policies and several political factors, but it also has been mentioned that additional evidence is further needed.
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Sequências terapêuticas no tratamento da diabetes tipo 2 – primeira abordagem
Teresa Risso1, Inês Ramos1, Cláudia Furtado1,2 1INFARMED – Autoridade Nacional do Medicamento e Produtos de Saúde, I.P., Lisboa, Portugal, 2Escola Nacional de Saúde Pública - Universidade Nova de Lisboa, Lisboa, Portugal
Objetivos: Em 2015, os encargos com antidiabéticos ascenderam a 239 M€ e a despesa com episódios hospitalares relacionados com diabetes foi 435 M€. O seguimento das orientações terapêuticas é importante para a utilização custo-efetiva dos medicamentos e melhoria dos resultados em saúde. Assim, importa identificar o padrão de utilização das terapêuticas e o seu nível de concordância com as orientações, em particular na primeira abordagem.
Métodos: Análise retrospetiva de dispensas de medicamentos antidiabéticos em farmácias comunitárias de Portugal Continental, entre 2014 e 2016. Selecionaram-se os doentes com diabetes tipo 2 new-to-therapy, sem dispensas nos primeiros 8 meses. Seguidamente, fez-se uma caracterização das terapêuticas prescritas no global e nos primeiros tratamentos, e de variáveis relacionadas com o utente e o local de prescrição.
Resultados: Globalmente (962.148 doentes), a Metformina isolada foi o medicamento mais utilizado (33,6%).
Foram selecionados 154.401 novos doentes, dos quais a maioria são mulheres (53,2%). O início da terapêutica é mais comum dos 60 aos 79 anos (47,4%). Os Cuidados de Saúde Primários prescrevem 59,5% destes tratamentos.
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A Metformina isolada foi o novo tratamento mais comum (66,9%), seguida da associação de Metformina com Inibidores da Dipeptidil Peptidase-4 (iDPP4 - 10,8%), iDPP4 isolados (4,9%) e Sulfonilureias (4%).
Conclusões: No que concerne à primeira abordagem terapêutica mais comum, a análise indicia uma adesão às orientações que recomendam a Metformina isolada como primeira opção. Esperar-se-ia uma maior utilização das Sulfonilureias como segunda opção mais frequente, em detrimento dos iDPP4. A utilização de associações também não parece de acordo com o preconizado nas orientações terapêuticas.
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The regional equity impact of community pharmacies on the access to a needle exchange program
Miguel Gouveia1, Margarida Borges2, Francesca Fiorentino2, Gonçalo Jesus2, José Pedro Guerreiro3, Maria Cary3, Suzete Costa3, António Vaz Carneiro2 1Catolica Lisbon School of Business and Economics, Lisbon, Portugal, 2Center for Evidence-Based Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal, 3Centre for Health Evaluation & Research (CEFAR), National Association of Pharmacies, Lisbon, Portugal
OBJECTIVES: The aim is to study the effects of community pharmacies (CP) on the regional equity and inequality of access to the national Needle Exchange Program (NEP).
METHODS: The availability of the service was characterized by the number of exchange sites per municipality and by the hours of access per unit (primary care, field units, mobile stations and CP). Two fairness concepts were studied: equity and inequality. The equity analysis studied the joint distribution of access hours and the municipalities’ purchasing power. Concentration curves and indices were estimated, with and without the CP. Since non-purchasing power related dispersion is also judged to be unfair in this case, the analysis also examined univariate inequality in hours of access. Regional inequality was captured by Lorenz curves and Gini indices. Dominance tests on the concentration and Lorenz curves were based on bootstrapping techniques, as were tests for the significance of differences in the concentration and Gini indices with and without CP.
RESULTS: Weekly hours of access per thousand inhabitants increase from 130 to 1577 with the inclusion of CP due to a higher number of exchange sites covering more municipalities and extended opening hours. The concentration curves and their indices are not significantly different with and without CP. However, CP significantly reduce inequality in access hours, with the Gini index for the distribution of hours of access improving from 0.755 to 0.282.
CONCLUSION: Community pharmacies’ participation significantly increases access to the NEP and substantially reduces its inequality at the regional level.
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Cost function for the Portuguese community pharmacies
Isabel Correia1,2, Tatiana Loureiro1, Sónia Queirós3,4, Paula Veiga1,2 1Universidade do Minho, Braga, Portugal, 2Núcleo de Investigação em Microeconomia Aplicada, UM, Braga, Portugal, 3Associação Nacional de Farmácias, Lisboa, Portugal, 4Universidade Técnica de Lisboa, Lisboa, Portugal
Objective: The principal aim of this paper is to estimate a cost function for the Portuguese community pharmacies.
Material and Methods: A translog cost function was estimated jointly with its cost minimizing input cost share equations, by means of a seemingly unrelated regression (SUR), and Structural Equation Model (SEM). The sample included data for 1169 pharmacies over the period 2010-2013, collected by Portuguese National Association of Pharmacies.
Results: Our findings suggest that the severe economic crisis and pharmaceutical policies adopted, resulted in a significant decline in the average profitability of a community pharmacy. There has been a significant reduction in the
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operational costs, that are, nonetheless, constrainted by the need to met the standards of the regulation. The estimated price elasticities of the demand for inputs is generally inelastic, which together with the low factor substitution, implies that costs are quite sensitive to increases in input prices.
The results indicate that the dimension of the community pharmacies, measured by volume of sales, is critical and pharmacies can benefit from economies of scale.
Conclusion: Cost data led to a conclusion of Public programmes and initiatives to retain and enhance pharmacy services in remote areas, should be evaluated.
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SESSÃO 11: New approaches for old issues (English stream)
Cost-effectiveness of high-throughput, non-invasive prenatal testing for fetal rhesus D status
Pedro Saramago, Stephen Palmer, Susan Griffin Centre for Health Economics - University of York, York, United Kingdom
Objective: To assess the cost-effectiveness of high-throughput non-invasive prenatal testing (HT-NIPT) for fetal rhesus D (RhD) status in avoiding unnecessary prophylactic anti-D immunoglobulin treatment in RhD-negative women found to be carrying an RhD-negative fetus.
Methods: A probabilistic cohort model was used to describe the antenatal care pathway and the long-term consequences of sensitisation events (e.g. miscarriage). The performance of HT-NIPT was derived from a systematic review and bivariate meta-analysis of 3 UK studies. Estimates of other relevant parameters were derived from literature sources. Five alternative strategies in which the use of HT-NIPT may impact on the existing post-partum care pathway were considered. A UK health service perspective was used and lifetime costs and effects were discounted at an annual rate of 3.5%. Sensitivity analysis was performed to key model parameters.
Results: The results indicated that HT-NIPT appeared cost saving but also less effective than current practice, irrespective of the post-partum scenario evaluated. Potential cost-savings with HT-NIPT appeared sufficient to outweigh the QALY loss associated with the small increase in sensitisations. A post-partum strategy, in which inconclusive test results are distinguished from positive results, was considered the optimal strategy. The results were also sensitive to the cost of the HT-NIPT.
Conclusions: HT-NIPT would reduce unnecessary treatment with anti-D immunoglobulin and appears cost saving when compared to current practice of providing prophylactic anti-D immunoglobulin to all RhD-negative pregnant women . The extent of any savings is highly sensitive to the additional cost that introduction of HT-NIPT would impose on the antenatal care pathway.
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Enhancing Health Technology Assessment through Multicriteria Decision Analysis: A roadmap of methods and tools to tackle challenges in the evaluation of medical devices Mónica Oliveira Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal
Health Technology Assessment (HTA) brings together evidence to help health decision-makers understanding the relative value of technologies and is key for improving health systems effectiveness, efficiency and sustainability. Several studies have shown the potential of using multicriteria decision analysis (MCDA) concepts, models and tools for evaluating technologies within HTA, but an effective use of these tools requires new research addressing how to develop theoretically sound models that include the perspectives of a large and representative number of stakeholders
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(going beyond the scope of small evaluation committees). Despite the practical relevance of evaluating Medical Devices (MDs), few studies exist in the area.
Within the framework of value-based health care and taking the perspective that the value of MDs is multidimensional, this study provides a roadmap of MCDA methods and tools to build models to evaluate MDs. Specifically, departing from HTA challenges identified in literature, the roadmap will cover: structuring methods that can assist in comprehensively defining all the relevant benefit, cost and risk impacts associated with the use of MDs; developing methods to evaluate MDs within common and transparent metrics that combine evidence with the perspectives from evaluators, and that address lack of information and measurement issues (e.g. preference dependence issues between evaluation criteria); approaches to enable the involvement of a large number of health stakeholders while promoting consensus in evaluations; and the use of web-based tools to enhance and facilitate evaluation.
Examples will be provided on how to implement these methods for decisions made by HTA agencies and hospitals.
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Estimating treatment effects under untestable assumptions with non-ignorable missing data: clarifying common misconceptions about the use of selection models.
Manuel Gomes1, Michael Kenward2, Richard Grieve2, James Carpenter2,3 1University College London, London, United Kingdom, 2London School of Hygiene and Tropical Medicine, London, United Kingdom, 3MRC Clinical Trials Unit at UCL, London, United Kingdom
Missing data are a recurring source of bias in observational studies and raise additional challenges for tackling the confounding. In many settings, the missing data are likely to be associated with unobserved values, where the missingness mechanism is said to be non-ignorable, and must be modelled together with the substantive model for the observed data. Non-ignorability poses key challenges for estimating treatment effects because the analysis model is often not identifiable without imposing further, untestable assumptions. For example, a popular econometric approach in health and social sciences, the Heckman selection model, has routinely been used for handling non-ignorable data, but in practice it requires: (i) additional parametric (e.g. distributional) assumptions, (ii) valid exclusion restrictions. The use of selection models for handling non-ignorable missing data has given rise to a number of fallacies amongst health and social scientists: i) one can test for the non-ignorable missingness mechanism; ii) one can assert that a particular selection process is correct; iii) the role of exclusion restrictions.
This paper critically examines the untestable assumptions underlying Heckman, multiple imputation and full-likelihood selection models when dealing with non-ignorable data for estimating treatment effects. We then assess bias and efficiency of the different methods across typical non-ignorable missing data mechanisms and alternative untestable assumptions through a simulation study. We illustrate the implications of method choice for inference in an observational study (REFLUX) that evaluates the effect of laparoscopic surgery compared to usual medical management on long-term quality-of-life (missing for 50% of patients) in patients with reflux disease.
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The role of physician and environment-specific factors in the adoption behaviour of new technologies
Eliana Barrenho1, Marisa Miraldo1, Carol Propper1, Ana Wheelock1, Mauro Laudicella2 1Imperial College London, London, United Kingdom, 2City University, London, United Kingdom
Despite substantial research documenting extensive variations in healthcare delivery and rates of innovation, relatively little is known about what drives physicians’ decisions.
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This research builds on the literature on adoption of innovation and practice variation aiming to understand the role of physician and environment-specific factors in the adoption behaviour. Particularly, we propose to assess how factors such as “school of thought” affect adoption of innovations. Moreover, we will assess how these decisions are shaped by environment-specific factors, in particular, competition and collaboration. Through collaborative practice we might expect practice spillovers across organizations to contribute to decreased variability in the technology adoption across practice settings. Hospitals might also engage in a “medical arms race” to attract more patients, leading to technology usage differences across providers.
We use patient level data for all colorectal cancer surgeries performed between 2000 and 2014 by 3,339 consultants and across 200 publicly funded hospitals in England. We match information on clinicians’ training and job experience back to 1992. The choice of colorectal cancer relates to its rapid innovation and high incidence, the associated costs for taxpayers, and the existence of guidelines intended to reduce variation in adoption.
Our results suggest that physician-specific factors, namely the “innate talent” are key drivers of the early adoption of laparoscopic techniques. Moreover, pressure from peers play a significant role on innovation adoption. We further show that clinical guidelines are generally regarded as a “tool” to persuade trusts to diffuse an innovation, rather than a determinant of innovation adoption.
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Expectations and risk attitudes: Evidence from a longitudinal survey in Tshwane, South Africa
Rui Leite1,2, Li-Wei Chao1,3,4,5,6, Helena Szrek1,5 1Center for Economics and Finance, University of Porto, Porto, Portugal, 2Faculty of Economics, University of Porto, Porto, Portugal, 3Population Studies Center, University of Pennsylvania, Philadelphia, USA, 4Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA, 5Porto Business School, Porto, Portugal, 6HIV/AIDS, STIs and TB Research Programme, Human Sciences Research Council, Pretoria, South Africa
Objectives: We investigate the relationship between measures of risk taking propensity and expectations about: (i) whether the surrounding economic environment will improve or deteriorate; and (ii) whether one’s own health status will improve or deteriorate.
Method: We use a sample of 2680 individuals interviewed for a three-wave longitudinal survey conducted in the Tshwane Municipality, South Africa, between 2009 and 2014. We elicited 5 and 11-point measures of risk attitudes following Dohmen et al. (2011), and 5-point measures of respondents’ one-year-ahead expectations about the economic environment and their own health. The survey included additional questions on entrepreneurial activity, health, and key socio- demographic variables. We use multivariate regression analysis to study how the willingness to take risks relates to economic and health expectations.
Results: We find that higher risk taking propensity measured on the 5-point scale is significantly predicted by better economic expectations (F(1, 2679)=6.23, p=0.013) and better health expectations (F(1, 2679)=5.04, p=0.025). The result regarding economic expectations generalizes to the sub-sample for which the 11-point measure is available, and holds under a variety of robustness checks. The result regarding health expectations does not generalize to that same sub-sample, nor does it hold under the same robustness checks.
Conclusion: We highlight a channel through which economic expectations can affect decisions involving risk, such as opening a business, investing in risky assets, or engaging in behaviors that pose health risks. Our results also suggest that further research is warranted to better assess the effects of health expectations on risk attitudes.
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Home is where your health is: the impact of internal migration on health and wellbeing.
Jack Higgins1, Bruce Hollingsworth1, Ian Walker2 1Health Economics at Lancaster (HEAL) - Lancaster University, Lancaster, United Kingdom, 2Economics Department - Lancaster University, Lancaster, United Kingdom
OBJECTIVES: There exists a large body of evidence looking at internal migration, with most considering labour market implications. Less attention has been paid, however, to the health implications of migration. This paper contributes to that literature by considering migration and mental health/wellbeing, and considering “tied-movers” as a special case.
METHODS: We use data from all waves of the British Household Panel Survey (BHPS), from 1991-2008, linked with five waves of Understanding Society (USoc), from 2010-2015, with access to local area-level data in each. We follow individuals over this period, including if and where households move. Alongside standard panel methods, we use relative house prices as an exclusion restriction in the migration equation for identification. Measures of psychosocial health and wellbeing, including the General Health Questionnaire (GHQ), are used as dependant variables.
RESULTS: In preliminary analysis, we find that migration is associated with worse mental health. In particular, moving is associated with a reduction in GHQ score, by around 1.1 scale points (p<0.05). When estimated separately by gender, we find the effects are larger for females than males. This can be considered an initial estimate of the tied-mover effects.
CONCLUSIONS: Preliminary results show that internal migration is associated with worse mental health, and there are proportionally worse effects for females than males. In terms of policy implications, removing barriers to commuting may mitigate the adverse health effects, if these are channeled through changing jobs as a result of migration. Also, migration may generate lower marriage surplus, and have implications for the probability of separation.
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SESSÃO 12: Qualidade de vida
Real-world evidence on heart failure: findings from 25 thousand patients in a portuguese primary care database
Raquel Ascenção1, Francesca Fiorentino1, Miguel Gouveia2, João Costa3, Paula Broeiro4, Cândida Fonseca5,6, Margarida Borges1 1Center for Evidence Based Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal, 2Catolica Lisbon School of Business and Economics, Lisbon, Portugal, 3Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal, 4Agrupamento de Centros de Saúde Lisboa Central, Unidade de Cuidados de Saúde Personalizados dos Olivais, Lisbon, Portugal, 5Centro Hospitalar de Lisboa Ocidental, Heart Failure Unit, Department of Internal Medicine and Day Hospital – Hospital São Francisco Xavier, Lisbon, Portugal, 6NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
OBJECTIVE: To determine the clinical and demographic characteristics of adult patients with a HF diagnosis in a Portuguese primary care comprehensive administrative database and to estimate the annual costs per patient.
METHODS: Observational study covering a primary care based population of 3.6 million patients in a large health region in Portugal. All adult users coded for HF with at least one visit in 2014 were selected. We analyzed patients’ characteristics, comorbidities, and resource use in 2014. Unit costs estimates were based on national sources.
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RESULTS: We identified 25,337 patients with HF. They were mostly women (58%) and on average 77±11 years old. The large majority of patients (93%) had at least one of the selected comorbidities present. About 65% had at least one of the selected medical test or diagnostic procedure done during 2014. The majority of patients (56%) had at least four office visits during one year. Angiotensin-converting enzyme inhibitor or angiotensin receptor blockers, beta-blockers, and aldosterone blockers were prescribed for 80%, 48% and 20% of patients, respectively. The average annual cost per patient was estimated at €552±348, of which 54%, 40% and 6% was associated to medications, medical visits and medical tests or diagnostic procedures, respectively.
CONCLUSIONS: HF patients are old, mostly women and characterized by multimorbidity. The number of patients identified is 30% of the expected according to a previous prevalence study suggesting that many patients are either not diagnosed or not coded. The average annual cost per patient was estimated to be about €550.
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EQ-5D: o que se ganha com a mudança do 3L para o 5L?
Luis Nobre Pereira1,2, Pedro Lopes Ferreira3,4, Lara Noronha Ferreira4,2, Patrícia Antunes5,4 1Universidade do Algarve - Centro de Investigação sobre o Espaço e as Organizações, Faro, Portugal, 2Universidade do Algarve-ESGHT, Faro, Portugal, 3Universidade de Coimbra - Faculdade de Economia, Coimbra, Portugal, 4Centro de Estudos e Investigação em Saúde da Universidade de Coimbra (CEISUC), Coimbra, Portugal, 5Administração Regional de Saúde do Centro, Coimbra, Portugal
O EQ-5D é um instrumento de medição baseado em preferências para utilização em estudos de avaliação económica (EAE). Para melhorar a sua sensibilidade, o poder discriminatório e reduzir o efeito teto, o grupo EuroQol expandiu recentemente este instrumento, adicionando dois níveis de resposta intermédia (EQ-5D-5L). Existe evidência recente que mostra que a qualidade de vida (QV) tende a ser menos valorizada no EQ-5D-5L, o que pode limitar o seu uso em EAE. O objetivo deste estudo foi comparar as duas versões do EQ-5D na população portuguesa.
Ambos os instrumentos foram aplicados a amostras representativas da população portuguesa em termos de idade, sexo e região (EQ-5D-3L:n=1.500; EQ-5D-5L:n=1.000). Os dados foram comparados em termos de valores em falta, inconsistência, efeito teto, nível de concordância, capacidade de descriminar subgrupos da população, estado de saúde reportado no sistema descritivo e índice EQ-5D.
O EQ-5D-5L apresentou maior percentagem de questionários completos, sendo consistente com outros estudos, e os participantes usaram todos os novos níveis dentro de cada dimensão. Verificou-se uma redução do efeito teto e uma concordância elevada entre os dois índices. A validade dos grupos foi confirmada para ambos os índices. Em relação às propriedades discriminativas, os índices não apresentaram diferenças estatisticamente significativas. Foi reportado um maior número de estados de saúde no EQ-5D-5L e uma QV inferior em comparação com o 3L.
O EQ-5D-5L contribuiu para uma redução significativa do efeito teto e parece ter um desempenho melhor do que o EQ-5D-3L. No entanto, é necessário algum cuidado na sua utilização em EAE.
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Levels and Determinants of Self-Medication in Portugal
Patrícia Pinto e Filipe, Pedro Pita Barros Nova School of Business and Economics, Lisbon, Portugal
Pressures over the National Health System (NHS) are a usual concern, either monetary costs, waiting lists or its general quality. Self-care, therefore, arises as an alternative to prevent, or at least ease, the clogging of our NHS.
We assess levels and determinants of self-medication in the Portuguese population, using a specifically designed survey, and identify which characteristics make an individual more prone to choose self-medication. Understanding
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what external factors promote self-medication is fundamental for a better understanding of which methods to use when designing policies.
First results, based on a statistical analysis over a surveyed sample representative of the Portuguese population, suggest that only 4.4% of the population engaged in a self-medicating behaviour the last time they felt sick, which is fairly low percentage of the population. From this 4.4%, 58.9% did it because their illness was similar to one in the past and 23.2% because they had the medication available at home. From these results, the next step is to identify individual characteristics influencing the decision taken and the vulnerability of individuals to certain constraints.
Despite the great number of determinants provoking a more systematic self-medication behaviour, the income gradient and the relationship of self-medication to barriers to health care is of particular interest. These aspects will reveal whether, or not, self medication should become a concern for health policy makers.
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TRANSTHYRETIN FAMILIAL AMYLOID POLYNEUROPATHY IMPACT ON HEALTH-RELATED QUALITY OF LIFE
Mónica Inês1, Teresa Coelho2,3, Isabel Conceição1,4, Lara Ferreira5, Mamede Carvalho1,4, João Costa6,7,8 1Faculty of Medicine, University of Lisbon, Instituto de Medicina Molecular, Lisbon, Portugal, 2Corino de Andrade Unit, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal, 3Department of Neurosciences, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal, 4Department of Neurosciences, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal, 5Universidade do Algarve, Faro, Portugal, 6Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal, 7Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal, 8Center for Evidence Based-Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
OBJECTIVES: The purpose of this study was to assess the health-related quality of life (HRQoL) impairment of Transthyretin Familial Amyloid Polyneuropathy (TTR-FAP) a rare, progressive, debilitating and life-threatening neurodegenerative disease.
METHODS: HRQoL was measured using the validated EuroQoL five dimensions three levels (EQ5D-3L) questionnaire being the index score (utility) calculated trough the Portuguese scoring algorithm. The Portuguese general population reference set (n = 1500) was pooled with TTR-FAP specific data (n = 1091) extracted from Transthyretin Amyloidosis Outcomes Survey (THAOS) registry. Demographic variables include gender and age. Ordinary least squares (OLS), tobit regression and generalized linear models (GLM) were specified in order to quantify TTR-FAP effect on HRQoL - as compared with Portuguese general population. Akaike information criteria (AIC) were used to select the most adequate model.
RESULTS: In a scale from -0.50 to 1.00 the average utility score was 0.76 (0.25) for general population, 0.823 (0.24) for TTR-FAP asymptomatic carriers (n=525) and 0.50 (0.37) for TTR-FAP patients (n=566). HRQoL decreases with age (p=0.012), females report worse health status than males (p<0.001) and a TTR carrier report similar health status than general population (p=0.069). Mean health utility is decreased in TTR-FAP patients by 0.35 (CI95%: -0.41 to -0.29) as compared with general population, 45% decrease (CI95%: 37%-52%) on HRQoL.
CONCLUSIONS: The preference-based utility measures used in this study adequately disentangle TTR-FAP disease impact on patient’s health-related quality of life. This study allows us to quantify the large HRQoL effect that TTR-FAP induces. This analysis could be conducted in other diseases.
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Normas portuguesas do EQ-5D-5L
Lara N. Ferreira1,2, Pedro L. Ferreira3,2, Luis N. Pereira1,4, Patricia Antunes5,2 1Universidade do Algarve-ESGHT, Faro, Portugal, 2Centro de Estudos e Investigação em Saúde da Universidade de Coimbra (CEISUC), Coimbra, Portugal, 3Faculdade de Economia, Universidade de Coimbra, Coimbra, Portugal, 4Centro de Investigação sobre o Espaço e as Organizações, Universidade do Algarve (CIEO), Faro, Portugal, 5Administração Regional de Saúde do Centro, Coimbra, Portugal
Os dados normativos de um instrumento podem ser utilizados como referência para analisar os efeitos dos cuidados de saúde, determinar o peso da doença e permitir comparações regionais ou nacionais. Embora o EQ-5D-5L seja um instrumento recente, já existem normas da população para outros países. Recentemente o EQ-5D-5L foi validado para Portugal, tendo também sido obtido o sistema de valores português. O objetivo deste estudo consistiu em obter as normas da população portuguesa para o EQ-5D-5L.
O EQ-5D-5L foi aplicado por entrevista telefónica a uma amostra aleatória da população portuguesa (n=1.000) estratificada por idade, sexo e região. O índice EQ-5D foi obtido usando o sistema de valores português. Calcularam-se os valores médios de utilidade por variável sociodemográfica e utilizados testes de hipóteses para comparar a qualidade de vida relacionada com a saúde (QVRS) entre subgrupos da população. A análise de clusters foi usada para classificar a população em grupos homogéneos, tendo em conta o índice de QVRS.
Quase metade dos entrevistados não apresentou problemas em todas as dimensões. O estado de saúde declina com o avanço da idade; as mulheres, indivíduos com menor nível de educação ou com uma doença crónica relataram pior QVRS.
Este estudo fornece dados de QVRS da população portuguesa medidos pelo EQ-5D-5L, os quais são usados para comparar o estado de saúde de subgrupos com a população portuguesa, interpretar os resultados reportados pelos pacientes e investigar efeitos dos tratamentos sobre o estado de saúde. A sua utilização é também muito importante em estudos de avaliação económica.
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SESSÃO 13: Avaliação económica
REAL-WORLD COMPARATIVE TREATMENT EFFECTIVENESS IN EARLY-ONSET TRANSTHYRETIN FAMILIAL AMYLOID POLYNEUROPATHY PATIENTS
Mónica Inês1, Teresa Coelho2,3, Isabel Conceição1,4, Marta Soares5, Mamede Carvalho1,4, João Costa6,7,8 1Faculty of Medicine, University of Lisbon, Instituto de Medicina Molecular, Lisbon, Portugal, 2Corino de Andrade Unit, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal, 3Department of Neurosciences, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal, 4Department of Neurosciences, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal, 5Centre for Health Economics, University of York, York, United Kingdom, 6Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal, 7Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal, 8Center for Evidence Based-Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
OBJECTIVES: This study aims to estimate long-term comparative survival in transthyretin familial amyloid polyneuropathy (TTR-FAP) using real-world data from the largest and oldest patient’s cluster.
METHODS: Registry data from the Portuguese TTR-FAP referral centers were merged encompassing 1,202 early-onset (< 50 years) treated patients carrying a Val30Met mutation and followed until 31 Dec 2016. Two different cohorts were compared: liver transplant (LTx) with procedure at stage 1 (n=855) and all tafamidis treated patients in Portugal (n=347), with a maximum follow-up of 25 years and 10 years, respectively. Kaplan-Meier survival estimates were
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obtained and a Cox proportional hazards model were used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (95%CI).
RESULTS: Treated patients with LTx have a median survival of 21.55 years (95% CI: 19.82– not estimable). Median survival was not reached in the tafamidis cohort, which exhibits a 10 years’ survival rate of 95.93% (95%CI: 89.76%-98.41%). LTx treated patients face operative risk and present a survival rate at 10 years of 76.14% (95%CI: 73.04%-78.93%). Conditional on treatment, tafamidis reduced mortality risk in early-onset patients (<50 years) by 86% compared with LTx (HR: 0.14; 95%CI: 0.06-0.26). Disease duration and higher age of onset are risk factors associated with increased mortality. No significant statistical effect was found for sex. Proportional hazards assumption holds (p= 0.6165).
CONCLUSIONS: Treatment with disease modifying oral tafamidis is associated with higher survival in early-onset patients. The prognosis is poorer among patients with longer disease which reinforces the need of earlier treatment.
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Vacina anti-HPV universal: avaliação económica em Portugal
Filipa Quinteiros ACeS Baixo Vouga (Unidade de Saúde Pública), Aveiro, Portugal, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal Introdução: A infeção por HPV (human papillomavirus) é responsável por uma variedade de lesões. Em 2008, a vacina tetravalente foi introduzida no Programa Nacional de Vacinação, apenas para raparigas com 13 anos. Em 2011, a Advisory Committee on Imunization Practices recomendou a vacinação tetravalente de rotina para rapazes a partir dos 11 anos. O objetivo do estudo foi analisar custos e benefícios da inoculação da vacina em ambos os sexos, segundo a perspetiva do Serviço Nacional de Saúde.
Métodos: Análise custo-benefício. Identificaram-se custos da vacina e de oportunidade e benefícios associados a cuidados de saúde. Para tal, estimaram-se as incidência e mortalidade atribuíveis aos serotipos da vacina, bem como, os casos e óbitos evitáveis por vacinação. Calculou-se o benefício líquido da vacinação e o rácio entre benefícios e custos.
Resultados: São necessárias 186180 inoculações, com um custo de oportunidade de 547369€. O custo total da vacinação universal, para o SNS, é de 6662804€. O valor dos benefícios é 41665129€, resultante da soma de 29640129€ (poupança com custos médicos devido a doença) com 12025000€ (vidas humanas salvas). O benefício líquido da intervenção é de 35002325€. Por cada euro investido na vacinação universal contra HPV existe um retorno de 6,25€.
Conclusões: A análise custo-benefício da vacinação tetravalente de rapazes e raparigas contra o HPV demonstrou vantagens relativamente à não vacinação, devendo aquela ser adotada. Mais estudos de avaliação económica são necessários para analisar os benefícios de um alargamento da vacinação anti-HPV aos rapazes, nomeadamente com a recente vacina nonavalente.
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Cost-Effectiveness of Pembrolizumab for the first-line treatment of metastatic non-small cell lung carcinoma in Portugal
Bernardete Pinheiro1, Joana Alarcão1, Luís Silva Miguel1, Min Huang2, Sheenu Chandwani2, Francisca Lopes3,4, Margarida Borges1 1Center for Evidence Based Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal, 2MSD, Kenilworth, USA, 3MSD, Paço de Arcos, Portugal, 4London School of Economics and Political Science, London, United Kingdom
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OBJECTIVE: To assess the cost-effectiveness of pembrolizumab compared to platinum-based chemotherapy in previously untreated patients with metastatic non-small cell lung carcinoma (NSCLC) with strong positive programmed death 1 protein ligands (PD-L1 ≥ 50%) expression in Portugal.
METHODS: A partitioned-survival model was parameterized using clinical data from a head-to-head phase III randomized clinical trial, KEYNOTE-024. A two-stage approach was used to adjust for crossover in the comparator arm. Utility was derived from KEYNOTE-024 using time-to-death weights. Portuguese-specific disease management resource use was estimated by a panel of clinical experts; resources were valued using national unit costs. The analysis was conducted from a societal perspective, assuming a life-time horizon and a 5% discount rate. Deterministic and probabilistic sensitivity analyses assessed the robustness of results.
RESULTS: Pembrolizumab increases average life expectancy by 3.8 undiscounted life-years (LY) and 2.1 discounted LY. This allows an increase of 1.7 quality adjusted life-year (QALY). Economic analysis shows that higher costs of pembrolizumab arm are mainly due to longer treatment duration and patient survival. The estimated incremental cost-effectiveness ratios (ICER) are 51,944€/LY and 64,205€/QALY. Deterministic sensitivity analysis shows that results are robust to most scenarios, but sensitive to treatment duration and parametric extrapolation options. Probabilistic sensitivity analysis resulted in a median ICER of 64,248€/QALY.
CONCLUSIONS: Considering usually accepted thresholds in oncology and the unmet need in metastatic NSCLC, the cost-effectiveness of pembrolizumab compared to chemotherapy regimen might be acceptable.
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Economic evaluation of the portuguese needle exchange programme in community pharmacies
Margarida Borges1, Miguel Gouveia2, Francesca Fiorentino1, Gonçalo Jesus1, Maria Cary3, José Pedro Guerreiro3, Suzete Costa3, António Vaz Carneiro1 1Center for Evidence-Based Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal, 2Catolica Lisbon School of Business and Economics, Lisbon, Portugal, 3Centre for Health Evaluation & Research (CEFAR), National Association of Pharmacies, Lisbon, Portugal
Objectives: In 2015 community pharmacies (CP) re-entered the NEP in Portugal. In this article, this change is evaluated from a cost-effectiveness perspective.
Methods: Health gains were measured by the number of HIV and HCV infections averted. The number of infections in each scenario was estimated based on a standard model in the literature (Jacobs et al, 1999) calibrated to national data. The costs per infection were taken from the national literature. The cost estimates of the NEP with CP include the manufacturing, logistics and incineration of injection materials. The results were presented as net-costs, i.e., incremental costs of the NEP with CP less the costs of additional infections avoided.
Results: Considering a 5-year horizon, NEP with CP would account for a 6.8% reduction (n=25) of HCV infections and a 6.5% reduction (n=22) of HIV infections. The present value of net savings generated by the participation of CP in the NEP was estimated at €2,073,347. Each syringe exchanged has an average discounted net-benefit of €3.01, already taking into account a payment to pharmacies per needle exchanged.
Conclusion: The participation of CP in the NEP leads to a reduction of HIV and HCV infections and generates savings for the health system above €2M. The NEP with CP is a dominant strategy compared to a NEP without CP. The intervention generates better health outcomes at lower costs, contributing to improve the efficiency of the public health system in Portugal.
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An economic evaluation of a complex nutrition intervention to prevent vitamin D deficiency
Magda Aguiar1, Lazaros Andronis1, Wolfgang Högler1,2, Emma Frew1 1University of Birmingham, Birmingham, United Kingdom, 2Department of Endocrinology and Diabetes, Birmingham Children’s Hospital, Birmingham, United Kingdom
Background: The high prevalence of vitamin D deficiency (VDD) and the diversity of the UK population pose a complex decision problem to policy-makers in the UK. For a sustainable and evidence-based policy to be designed, modelling scenarios of long-term VDD prevention are necessary.
Aim: To estimate the cost effectiveness of preventing VDD in the UK through a model based cost-utility analysis.
Methods: A state transition, microsimulation model was built to simulate four different scenarios of preventing VDD in the UK population: 1) wheat flour fortification; 2) supplementation of at-risk groups 3) combination of flour fortification and supplementation of at-risk groups; 4) no additional intervention. The model adopts a societal perspective. The population was followed through a 90 year time-horizon and the primary outcome was the incremental cost-effectiveness ratio, measured in cost/QALY. Data collected to inform the model included primary data on the health-related quality of life of patients with symptomatic vitamin D deficiency, and cost and resource use data from the relevant sectors, including the National Health Service (NHS), local public health authorities, the food industry, patients and consumers. Uncertainty analyses, including one-way sensitivity analysis and probabilistic sensitivity analysis were performed.
Discussion: This is the first comprehensive economic evaluation of UK vitamin D policy. It highlights how a model-based analysis can evaluate complex public health interventions with inter-sector costs and benefits. Main results will be presented, as well as the challenges of developing a decision analytic model in public health.
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SESSÃO 14: Ageing (English stream)
The cost of social isolation for elderly hip fracture patients in England: delayed discharges
Filipa Landeiro1, Seamus Kent1, M Kassim Javaid2, Ku Shah3, Claire Pulford3, Alastair Gray1, Jose Leal1 1Health Economics Research Centre, University of Oxford, Oxford, United Kingdom, 2Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom, 3John Radcliffe Hospital, Oxford, United Kingdom
Objective: To assess the impact of social isolation on delayed hospital discharges and the corresponding costs.
Methods: A prospective cohort study was conducted in which 260 hip fracture patients aged 75 years or older were consecutively admitted over a one-year period in 2014/15 to the Trauma Service at the John Radcliffe Hospital in Oxford. Social isolation was assessed using the Lubben Social Network Scale. A generalized linear model with a log link and gamma variance was used to assess the number of days of delayed discharges in relation to level of social isolation, controlling for potential confounders. Costs of delayed discharges were estimated using a Healthcare Resource Group approach.
Results: Mean age at admission was 86.2 years and mean length of stay was 16.8 days. 227 (87.0%) patients had a delayed discharge, with an average of 8.4 days per patient with a delay. 44.1% of all hospital days were deemed unnecessary. Compared to patients with a low risk for social isolation, hospital stays were longer by 3.8, 3.1, and 4.0 for those with a moderate risk for social isolation, high risk or socially isolated, respectively. The mean cost of delayed discharge per patient with delayed discharge, was £2,328, equivalent to 27.3% of the mean cost of a hip fracture.
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Conclusion: In order to reduce costs associated with delayed discharges, improved strategies should be found for provision of post-acute care for socially isolated individuals.
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Partners in Care! Ageing Couples and Informal Caregiving in Europe
Luís Filipe Nova School of Business and Economics, Lisbon, Portugal
The ageing of the population has brought new challenges to modern societies. The need to care for the elderly has incited a quest to find the best policies to ensure a good life quality in its later stages. But to do so it is essential to understand the key issues associated with ageing, both affecting the elderly and the corresponding society. This paper focus on informal caregiving, in particular, on the help provided by partners to respective partners in need. Resorting to the Survey of Health, Ageing and Retirement in Europe (SHARE), the paper analyzes the impact of providing informal care to a partner on the health outcomes of the provider. Taking advantage of the existing couples' matching code, patient’s data is input on the caregiver observations, so the analysis is conditioned on patient’s characteristics.
The results show that physical health of partner caregivers is not influenced by the act of caring, while mental health is negatively affected by it. When caring for a partner is interacted with employment, results state that caring and working does imply lower physical health. This suggests that caring for a partner have detrimental impacts on the health of the caregiver when it increases daily workload. Working and caring may just be too exhausting!
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Estimation of the future impact of the aging of people living with Human Immunodeficiency Virus (HIV) in Portugal
Francesca Fiorentino1, Rita Sousa1, Miguel Gouveia2, Margarida Borges1, António Vaz Carneiro1, João Costa1 1Center for Evidence Based Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal, 2Catolica Lisbon School of Business and Economics, Lisbon, Portugal
Objectives: To estimate the consequences of the aging of Portuguese People living with HIV (PHIV) in terms of prevalence of relevant non-oncological comorbidities and incidence of oncological comorbidities in a 20-year horizon.
Methods: Firstly, we distributed the HIV prevalence by age-group and sex (the stock). Secondly, we estimated the incidence and mortality over time (the flows). Finally, we estimated the prevalence of HIV over time updating the stock with the flows. The incidence and mortality due to HIV in the next 20 years were extrapolated from historical data using econometric models. Mortality due to other causes was assumed time-independent. The prevalence of non-oncological comorbidities and incidence of oncological comorbidities in non-HIV people was estimated using national sources. Relative-risk of prevalence and incidence of comorbidities among PHIV versus non-HIV people came from the international literature.
Results: The number of PHIV aged 50+ will double in the next 20 years, representing 80% of the estimated overall prevalence in 2037. The prevalence of ischemic heart disease, hypertension, diabetes, renal failure and osteoporosis will increase by 119%, 60%, 120%, 108% and 158%, respectively. The incidence of anal, vagina/vulva, penis, liver, skin, lung and prostate cancer will increase by 133%, 166%, 140%, 119%, 90%, 135% and 237%, respectively. The incidence of non-Hodgkin lymphoma is expected to be 17% lower in 2037.
Conclusions: The clinic-demographic profile of the PHIV in Portugal will change in the next decades, with increasing number of older patients with multiple morbidities, with a significant additional burden for the National Health System.
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Selfie Ageing Index: an index for the self-assessment of healthy and active ageing
Judite Gonçalves1, Isabel Gomes2, Maria Amália Botelho3, Pedro Pita Barros1, Miguel Fonseca2 1Universidade Nova de Lisboa, Nova School of Business and Economics, Lisbon, Portugal, 2Universidade Nova de Lisboa, Faculty of Sciences and Technology, Lisbon, Portugal, 3Universidade Nova de Lisboa, Nova Medical School, Lisbon, Portugal
This study develops the Selfie Ageing Index (SAI), an index for the individual self-assessment of healthy and active ageing.
The SAI is based on the Biopsychosocial Assessment Model (Botelho 2000). Questions such as “Do you have trouble going around the house?”, “Have you felt downhearted lately?” and “Do you have someone on your entourage you can talk to about your worries?” are used to assess the physical, mental, and social status of the individual. An ordered probit model links each person’s answers to her self-assessed health status and generates her SAI score. This score is compared with those of other persons in the same age group, allowing the individual to grasp her ageing process compared to her peers’. This method to construct the SAI is developed using data from the Survey of Health, Ageing and Retirement in Europe (SHARE) for Portugal and the Study of the Ageing Profiles of the Portuguese Population (EPEPP).
As an illustration, a 60-year-old married person with someone to talk to, 4 years of education, blue-collar occupation, adequate weight, without troubles going around the house or performing the activities of daily living, no symptoms about the emotional status, with good time awareness, smoker, and who exercises occasionally has a score of 0.74 on a 0-1 scale, belonging to the top quintile with respect to all individuals in the sample aged 58-62.
The SAI will be implemented into a free website/mobile app, so that each person can learn and deal with her own ageing process.
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Retirement and Health Plan choices: Evidence from Swiss Administrative Data
Mujaheed Shaikh1, Tobias Mueller2, Lukas Kauer3 1Vienna University of Economics and Business, Vienna, Austria, 2University of Bern, Bern, Switzerland, 3CSS Institute of Empirical Health Economics, Luzern, Switzerland
We analyze the effect of retirement on health plan choices and health care expenditures using administrative data from one of the biggest health insurance companies in Switzerland. We apply a fuzzy regression discontinuity design exploiting the Swiss retirement eligibility cutoff at the age of 65 for men and 64 for women. Our findings provide evidence that newly retirees significantly lower their monthly premium after retirement by about 40 Swiss Francs (approximately 40 US Dollars). At the same time, they do not adjust their deductible level which in turn would result in the acceptance of more financial risk and consequently a premium rebate. Instead, they are significantly more likely to sign up for managed care plans which restrict free choice of health care providers and force individuals to consult a general practitioner in a first step before seeing a specialist ("Gatekeeper model"). Also, the elderly show some extent of price sensitivity as they are signicantly more likely to switch to other health insurance providers as a response to retirement. Finally, our analysis shows that the health plan adjustments do not have direct implications for the health care utilization of the elderly as we do not find evidence for significant retirement effects on individual health care expenditures.
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Access to Medicines by the Portuguese Elderly Population: Overview
Pedro Pita Barros, Pedro Carvalho Nova School of Business and Economics, Lisbon, Portugal
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This paper characterizes the Portuguese Elderly group without access to medicines due to financial constraints. Data were obtained from a nationally representative survey – Survey on the Use of Health Services. Moreover, the associated factors of not having access to medicines were estimated using a logistic regression model.
The results indicate that the proportion of elderlies without access to medicines due to financial constraints varies between 15.65% and 19.22% depending on the threshold used to define the elderly age group: 50 and 65 years, respectively.
Additionally, the lack of access to medicines is particularly concentrated in narrower population groups such as widow/widower, elderlies with less years of schooling or those with unhealthy habits. Indeed, our model shows that being a widow/widower, low levels of education, drinking alcohol regularly and some chronic diseases are associated with a higher probability of not buying all the required medicines.
This study suggests that a substantial proportion of Portuguese elderlies do not have access to medicines. Therefore, policymakers’ efforts should focus on improving financial protection of this vulnerable group.
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SESSÃO 15: Sistemas de saúde II
Influência da Organização dos Cuidados de Saúde Primários na Utilização do Serviço de Urgência
Joana Vales1, Álvaro Almeida2 1Centro Hospitalar do Tâmega e Sousa, E.P.E, Porto, Portugal, 2Universidade do Porto, Faculdade de Economia, Porto, Portugal
A influência do modelo organizativo dos cuidados de saúde primários (CSP) na utilização de Serviços de Urgência (SU) foi avaliada através de três modelos: um modelo de utilização adequada, definida a partir da prioridade atribuída pela Triagem de Manchester; um modelo de intensidade de utilização do SU; e um modelo de severidade no acesso ao SU. Em todos os casos, a variável dependente foi relacionada com o tipo de unidade funcional dos CSP em que o utente se encontra inscrito (UCSP, USF A e USF B), com a atribuição de médico de família, e com outras variáveis relevantes. Os modelos foram estimados com base numa amostra de cerca de 117 mil episódios de urgência de um centro hospitalar que dispõe de dois SU, uma urgência básica e uma médico-cirúrgica. Os resultados indicam que o modelo organizativo dos CSP influencia a utilização do SU, já que os utentes das UCSP utilizam mais estes serviços e de forma considerada menos adequada do que os utentes inscritos em USF. Contudo, são também aqueles utentes que registam episódios de maior severidade, devido, provavelmente, à dificuldade de acesso ao médico de família. Concluiu-se que o tipo de unidade funcional dos CSP em que o utente se encontra inscrito e a atribuição de médico de família influenciam significativamente a utilização dos SU.
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Does transparency and accountability in health systems means the same for different countries?
Vítor Raposo1,2,3, Pedro Lopes Ferreira1,2 1Centre of Health Studies and Research of the University of Coimbra (CEISUC), Coimbra, Portugal, 2Faculty of Economics of the University of Coimbra (FEUC), Coimbra, Portugal, 3Centre for Business and Economics Research (CeBER), Coimbra, Portugal
AIM: Siddiqi et al. (2009) presented a framework for assessing health system governance (HSG) at national and sub-national levels using 10 principles that include, in addition to others, transparency and accountability. This framework helps to identify problems in HSG at policy and operational levels and points to interventions for its improvement. The aim is to make a comparative analysis between several developed countries in the dimensions of transparency and accountability
METHODS: Data used from Health Systems in Transition (HiT) for 28 countries. Two comparative applications are made: first, a content analysis under the topic to identify different meanings and dimensions considered by countries; second, a review at national and sub-national levels using the HSG framework proposed by Siddiqi et al. (2009).
PRELIMINARY RESULTS: The topic transparency and accountability from HiTs is not fulfilled for 8 countries (Finland, Germany, Greece, Ireland, Portugal, Slovenia, Spain, USA). The topics covered by each country vary in size, type and quantity. Some countries have very detailed topics and issues and others have much little to considerer. At a first glance, it seems that just some countries fulfil the requirements under the HSG framework considered in the analysis.
CONCLUSIONS: The topics transparency and accountability are analysed in the majority of the countries belonging to the HiTs. However, it seems, based on the preliminary results, that the meanings, dimensions and issues include by each country are diverse and not the same for all.
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Determinantes da despesa corrente pública em saúde em Portugal
Gisele Braun Conselho das Finanças Públicas, Lisboa, Portugal
A despesa pública com saúde nos países da OCDE tem diminuído ao longo dos últimos anos. No entanto, é importante garantir que a redução ocorra sobre os elementos do gasto público que não adicionam valor à saúde, mantendo aqueles que garantem o acesso universal aos cuidados de saúde e a qualidade dos serviços prestados, além dos que contribuem para a redução das desigualdades no acesso e no tratamento. Este estudo realiza, portanto, uma análise quantitativa sobre os principais determinantes da despesa corrente pública com saúde em Portugal, identificando elementos não apenas demográficos, mas também aqueles que refletem o ambiente institucional e as políticas públicas implementadas: produto interno bruto per capita, rácio de dependência, preços relativos em saúde e índice de qualidade. Utilizando dados nacionais agregados, para os anos entre 1982 a 2014, os resultados obtidos por regressão linear indicam que o produto interno bruto per capita, os preços relativos em saúde e o índice de qualidade influenciam positivamente a despesa corrente pública com saúde em Portugal. Em contrapartida, não foi encontrado efeito significativo do rácio de dependência da população idosa sobre a despesa.
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Fatores associados com a adoção de normas de orientação clínica no tratamento de infeções urinárias nos Cuidados de Saúde Primários
Ana Catarina Silva1, Nuno Sousa Pereira2,1, Susana Oliveira1,3 1Faculdade de Economia do Porto, Porto, Portugal, 2CEF.UP, Porto, Portugal, 3Porto Business School, Porto, Portugal Normas de Orientação Clínica (NOC) são uma componente cada vez mais relevante dos sistemas de saúde na procura de qualidade e eficiência dos serviços prestados. No entanto, o estudo sobre o processo de difusão das NOCs é ainda bastante limitado. Neste estudo procura-se quantificar os determinantes da adoção da NOC relativa à prescrição de antibióticos para tratamento de infeções urinárias. Para tal, foram analisados 509 episódios de infeções urinárias não complicadas em mulheres, de 16 unidades de um ACeS da ARS Norte, relativos às prescrições antibióticas de 82 médicos no período entre novembro e dezembro de 2015 e foram tidos em consideração características do prescritor, do utente, mas também fatores organizacionais, como o tipo de estrutura organizacional ou o número de médicos na unidade. Em particular, procurou-se quantificar de que forma é que trabalhar com prescritores que adotam a norma aumenta a probabilidade de um médico a prescrever igualmente. Tendo como base um modelo de regressão logística em duas fases, analisou-se, primeiro, a escolha do antibiótico e, utilizando estes resultados, a decisão sequencial de prescrever a dosagem apropriada. Resultados preliminares demonstram que os prescritores femininos tendem a não respeitar a norma, que a adoção por colegas aumenta a pressão para o cumprimento da NOC e que há uma menor probabilidade de escolha da dose certa nos doentes mais idosos. Adicionalmente, procurou-se avaliar o impacto económico do não cumprimento da NOC. Estimou-se que a utilização dos antibióticos adequados na posologia correta permitiria reduzir o custo de tratamento em cerca de 40%.
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FUNÇÃO DE PRODUÇÃO DE SAÚDE PARA O BRASIL: ANÁLISE PELO MODELO DE GROSSMAN
José Rodrigo Gobi, Pietro André Telatin Paschoalino, Cássia Kely Favoretto Costa, Marina Silva da Cunha Universidade Estadual de Maringá, Maringá-PR, Brazil
OBJETIVOS: Estimar funções de produção de saúde para o Brasil com base no modelo teórico de Grossman.
MÉTODOS: Pesquisa descritiva e analítica desenvolvida a partir de informações da Pesquisa Nacional de Saúde (PNS) de 2013. Foram estimados três modelos Probit, no primeiro considerou-se todas as variáveis explicativas como exógenas, sem impor restrições. O segundo abordou as variáveis explicativas como exógenas, restringindo a amostra para ocupados com cônjuge. Por fim, no modelo 3, a escolaridade é classificada como endógena, com a mesma restrição imposta ao modelo anterior.
RESULTADOS: Observou-se que menores níveis de idade, maior escolaridade, possuir plano de saúde, não ser obeso, ser do sexo masculino, não fumar e não ter diagnostico de doenças crônicas estão associados com melhor saúde nos três modelos analisados. Nota-se ainda que o efeito da educação sobre a saúde aumenta ao se corrigir o problema de endogeneidade nessa variável. O aumento no nível de escolaridade eleva em 3,4% e 3,2% a probabilidade de o indivíduo avaliar-se com saúde muito boa ou boa, considerando os modelos 1 e 2 respectivamente. Ao corrigir o problema de endogeneidade, no modelo 3, maior escolaridade eleva em 16,3% a probabilidade do indivíduo se avaliar mais saudável. Ademais, residir nas regiões Norte e Nordeste brasileiras apresentaram menor probabilidade de o indivíduo se avaliar saudável.
CONCLUSÕES: Observa-se que políticas educacionais e ações que estimulem hábitos saudáveis podem ser consideradas fundamentais para a produção de melhor saúde, seja por meio de ações que estimulem a boa alimentação ou desestimule o consumo tabágico.
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Efeito da mudança do modelo organizacional nos resultados dos indicadores de desempenho não incentivados em Cuidados de Saúde Primários
Miguel Azevedo1,2, Álvaro Almeida1 1Faculdade de Economia - Universidade do Porto, Porto, Portugal, 2Administração Regional de Saúde do Norte, Porto, Portugal
Uma das críticas habituais aos programas de pagamento por desempenho é a de que podem enviesar a atividade dos prestadores de cuidados de saúde, incentivando-os a melhorar a sua performance nas atividades sujeitas a avaliação, em detrimento das atividades não sujeitas a avaliação.
Nos cuidados de saúde primários (CSP) portugueses, as Unidades de Saúde Familiar (USF) são avaliadas com base em indicadores contratualizados, mas também são medidos indicadores não incentivados. Utilizou-se um modelo de diferença-nas-diferenças para avaliar se a transformação de uma Unidade de Cuidados de Saúde Personalizados (UCSP) em USF modelo A, e a transformação de USF A para USF modelo B, incentivam a uma melhoria da performance mesmo nas áreas não avaliadas, medida pela evolução dos indicadores calculados mas não contratualizados, no período de 2012 a 2015.
Os resultados sugerem que a criação de USF (passagem de UCSP a USF A) implica uma melhoria da performance mesmo em indicadores não contratualizados, sendo a diferença significativa em um quarto dos indicadores analisados. Também na passagem de USF A a B se observa uma melhoria da performance, mas neste caso apenas um dos indicadores analisados mostra uma diferença significativa.
Concluímos que a mudança de modelo organizacional nos CSP se reflete na melhoria da performance que é extensiva aos indicadores não incentivados, pelo que não se encontra evidência que suporte a hipótese de os incentivos enviesarem a atividade.
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RESUMOS / ABSTRACTS
POSTERS
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SESSÃO POSTERS A
Cost-effectiveness Analysis of Crizotinib for Untreated Anaplastic Lymphoma Kinase-Positive Advanced Non-Small-Cell Lung Cancer in Portugal
Pedro Saramago1, Monica Ines2, Frederico Saraiva2 1Centre for Health Economics - University of York, York, United Kingdom, 2Pfizer - Portugal, Lisbon, Portugal
OBJECTIVES: To evaluate the cost-effectiveness of crizotinib in the treatment of ALK-positive non-small cell lung cancer (ALK+NSCLC) in the Portuguese NHS.
METHODS: A previously developed and validated state transition Markov cohort model was used. The economic model was adapted to consider treatment strategies relevant to the Portuguese setting and clinical practice. Relevant epidemiological and quality of life data were incorporated in the model. Economic/resource use evidence elicited from a panel of six Portuguese clinical experts with extensive clinical experience was incorporated. First-line treatment with pemetrexed and platinum followed by switch to crizotinib (second-line) and best supportive care (third-line) in case of disease progression was compared with first-line treatment with crizotinib followed by switch to docetaxel (second-line) and best supportive care (third-line). Unit costs (medicines, procedures and hospitalizations) were extracted from Portuguese official sources. A societal perspective was adopted. Both costs and effects were discounted at 5%, and a lifetime horizon was considered. Univariate sensitivity analyses were performed over key model parameters.
RESULTS: A treatment strategy considering crizotinib as first-line option was found to be more costly per patient, but also more effective than one considering first-line pemetrexed and platinum for patients with ALK+NSCLC. This resulted in an incremental cost-effectiveness ratio (ICER) of 29326€ per LY gained (48691€ per QALY gained). Sensitivity analyses over key model parameters indicated that the base case results were generally robust.
CONCLUSIONS: Compared with standard first-line chemotherapy, first-line treatment with crizotinib in patients with ALK+NSCLC can be considered a cost-effective option for the Portuguese NHS by commonly used criteria.
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Estilos de vida e saúde auto avaliada: uma análise estratificada por renda para o Brasil
Lívia Madeira Tríaca1,2, Marco Túlio Aniceto França2, Cesar Augusto Oviedo Tejada3, Marília Cruz Guttier3 1Fundação Universidade Federal do Rio Grande, Rio Grande, Brazil, 2Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil, 3Universidade Federal de Pelotas, Pelotas, Brazil
Objetivo: Investigar se as diferenças apresentadas na prevalência de saúde boa entre os estratos de renda podem ser explicadas pelas diferenças de prevalência em relação a comportamentos saudáveis.
Método: Foram usados dados brasileiros da Pesquisa Nacional de Saúde 2013. A medida de saúde utilizada foi a saúde autovaliada categorizada em muito boa/boa e regular/ruim/muito ruim. Cinco comportamentos foram analisados: dieta, atividade física, tempo em frente à televisão, consumo de álcool e tabagismo. A análise foi realizada através de uma regressão de Poisson. Todas as análises foram estratificadas por classe de renda.
Resultados: As correlações parciais para cada estilo de vida e as classes de renda baixa e alta mostram que os estilos de vida ditos como saudáveis são positivamente correlacionados com a classe de renda alta e negativamente com a classe de renda baixa, com exceção para o consumo de álcool. Na análise ajustada, para a classe de renda baixa apenas consumo de álcool e tabagismo apresentaram associação significativa. Para indivíduos de classe de renda média, quatro das variáveis analisadas apresentaram associação: dieta, atividade física, álcool e tabagismo. Para indivíduos de classe de renda alta apenas atividade física e consumo de álcool apresentaram associação significativa com o desfecho.
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Conclusões: Os resultados mostram que a influência de comportamentos saudáveis na saúde autoavaliada difere de acordo com estrato de renda. Porém, a maior prevalência de comportamentos não saudáveis entre os indivíduos mais vulneráveis economicamente não demonstraram ser um fator dominante para explicar as diferenças no estado de saúde.
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Avaliação dos custos da Consulta de Planeamento Familiar da USF da Barrinha em 2016.
Isabel Tomás, Cristina Coelho, Fernando Fardilha, Isabel Gomes, Marília Diogo, Tiago Carvalho, Lima Nogueira, Inês Trigo, Constança Oliveira, Cristiana Conceição, Clara Silva USF da Barrinha, Ovar, Portugal
Introdução: O Plano de Acompanhamento Interno de 2016 da USF da Barrinha pretendeu melhorar os cuidados na Saúde da Mulher, obtendo ganhos em saúde e aumentando a eficiência da prestação de serviços. Foi estimado o custo da consulta de planeamento familiar (PF) em 2016 para aumentar a eficiência.
Métodos: Consultou-se MIM@UF, registos de gestão de stock da USF e do ACeS Baixo Vouga (BV). Calculou-se a proporção de custos com contracetivos do ACeS BV comparando 2015 com 2014 e 2016 com 2015. Calculou-se a proporção de custos com contracetivos cedidos pelo ACeS à USF em 2016, comparando com 2015. Calculou-se a proporção de custos com total de contracetivos e citologias da USF em 2016 comparando com 2015. Estimou-se o custo total (contracetivos, citologias e material consumível) da consulta de PF por utilizadora em Abril e Dezembro de 2016.
Resultados: O gasto com contracetivos do ACeS BV em 2015 aumentou para 122,54% comparando com 2014, e em 2016 aumentou para 136,19% comparando com 2015. A USF da Barrinha gastou 3,32% do total dos gastos com contracetivos do ACeS BV em 2015 e 1,46% em 2016. Em 2016 a USF gastou 72,82% do total gasto pela USF em 2015. Em 2016, o custo total da consulta de PF, por utilizadora, em abril foi €3,27 e em dezembro foi €5,05.
Discussão: Houve redução dos custos com contracetivos de 2015 para 2016 na USF. O custo total por utilizadora aumentou entre Abril e Dezembro de 2016, motivado pelas consultas de reavaliação.
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Análise Custo Efetividade da Metadona, como tratamento de manutenção.
Davide Cruz1, Oscar Lourenço2, José Almeida3 1Unidade de Desabituação de Coimbra, Coimbra, Portugal, 2CeBER; FEUC, Coimbra, Portugal, 3Divisão de Intervenção nos Comportamentos Aditivos e nas Dependências, Coimbra, Portugal
Este é um trabalho de investigação que pretende fazer uma avaliação económica, de custo efetividade da metadona como tratamento de manutenção em consumidores de opiáceos, nomeadamente de heroína. Este trabalho está a ser desenvolvido no âmbito do Mestrado em Gestão e Economia da Saúde, da Faculdade de Economia da Universidade de Coimbra. O objetivo do estudo é avaliar os benefícios que o tratamento com metadona tem, não apenas para os utentes, como também para a sociedade em geral. A metadona é um fármaco (opióide sintético) que tem no cérebro uma atividade similar ao da substância de consumo (a heroína), é considerado um agonista. Para se proceder à avaliação, estamos a construir um modelo de Markov, para comparação dos utentes em tratamento de metadona e os consumidores de heroína, fora deste programa de tratamento. Depois da construção do modelo, este irá ser apresentado a um grupo de peritos da área, para posterior avaliação e validação do mesmo. Neste momento ainda não é possível apresentar os resultados do estudo, mas espera-se demonstrar a efetividade do tratamento, através do custo (em euros) face às medidas de qualidade de vida, esperança média de vida, morbilidades associadas (seja HIV, hepatites, tuberculose), bem como o aumento da produtividade e outros benefícios sociais (como a redução da criminalidade, por exemplo).
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HEALTH-RELATED QUALITY OF LIFE IN PATIENTS WITH TRANSTHYRETIN FAMILIAL AMYLOID POLYNEUROPATHY IN PORTUGAL
Mónica Inês1, Teresa Coelho2,3, Isabel Conceição1,4, Teresa Bago D'Uva5, Mamede Carvalho1,4, João Costa6,7,8 1Faculty of Medicine, University of Lisbon, Instituto de Medicina Molecular, Lisbon, Portugal, 2Corino de Andrade Unit, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal, 3Department of Neurosciences, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal, 4Department of Neurosciences, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal, 5Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, Portugal, 6Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal, 7Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal, 8Center for Evidence Based-Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
OBJECTIVES: Transthyretin Familial Amyloid Polyneuropathy (TTR-FAP) is a rare, progressive, debilitating and life-threatening neurodegenerative disease. The purpose of this study was to assess the health-related quality of life (HRQoL) factors for TTR-FAP patients.
METHODS: HRQoL was measured using the validated EuroQoL five dimensions three levels (EQ-5D-3L) questionnaire being the index score calculated trough the Portuguese scoring algorithm. TTR-FAP patients specific data (n = 566) were extracted from Transthyretin Amyloidosis Outcomes Survey (THAOS) registry last visit. Demographic variables include gender and age. Clinical variables include disease onset (early/late), disease stage, liver transplant and pharmacologic treatment. Different econometric specifications were carried out to select the most adequate regression model.
RESULTS: In a scale from -0.50 to 1.00 the average utility score is 0.50 (0.37) for TTR-FAP patients. Within TTR-FAP population, significant statistical effect (p-value <0.005) was observed for age, pharmacologic treatment and disease severity. No significant statistical effect was observed for gender, late onset patients (>50 years) and liver transplant.
CONCLUSIONS: The preference-based utility measures used in this study adequately disentangle TTR-FAP impact on patient’s quality of life and allow discriminating across different disease stages, pharmacologic treatment and demographic characteristics. Longitudinal data analysis can improve liver transplant associated utility estimates capturing variations between before and after this invasive procedure.
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PREVALENCE OF TRANSTHYRETIN FAMILIAL AMYLOID POLYNEUROPATHY IN PORTUGAL DURING YEAR 2016
Mónica Inês1, Teresa Coelho2,3, Isabel Conceição1,4, Filipa Duarte-Ramos5, Mamede Carvalho1,4, João Costa6,7,8 1Faculty of Medicine, University of Lisbon, Instituto de Medicina Molecular, Lisbon, Portugal, 2Corino de Andrade Unit, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal, 3Department of Neurosciences, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal, 4Department of Neurosciences, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal, 5Social Pharmacy Department, Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal, 6Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal, 7Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal, 8Center for Evidence Based-Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
OBJECTIVES: The purpose of this study was to estimate Transthyretin Familial Amyloid Polyneuropathy (TTR-FAP) prevalence in Portugal, a progressive, rare, debilitating and life-threatening neurodegenerative disease as the country has one of the largest TTR-FAP clusters in the world and recent epidemiologic estimates are lacking.
METHODS: TTR-FAP patient’s medicines utilization is fully funded by National Health System in Portugal. Portuguese electronic prescription system became more generalized recently, allowing central monitoring and validation of medicines prescription and dispensing. TTR-FAP anonymized patient’s data was extracted for year 2016 and validated
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trough an algorithm. The most frequent municipality used for medicines dispensing by each patient was used as a proxy for residence. Portuguese population by municipality was extracted from official sources. Prevalence was reported as number of cases per 100 000 adult-inhabitants. Poisson distribution was assumed to estimate 95% confidence intervals (95%CI).
RESULTS: Over year 2016, 2150 TTR-FAP anonymized adult patients were registered in prescription national database. A prevalence of 26,32per 100 000 adult-inhabitants (95%CI: 25,22 - 27,45) was estimated for TTR-FAP in Portugal mainland. The disease is spread across more than half of the Portuguese municipalities.
CONCLUSIONS: We can conclude that Portuguese electronic prescription database is useful, relevant and an accessible strategy to estimate the prevalence of some diseases in Portugal. We can estimate that TTR-FAP disease has a high prevalence in Portugal and it is disseminated across the country. These results are informative to support a patient-centered healthcare resource distribution.
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Desigualdade socioeconômica na mortalidade infantil no Estado da Bahia/Brasil, 2000-2010
Péres Geandry1, Perelman Julian2 1Escola Nacional de Saúde Pública - ENSP / UNL, Lisboa, Portugal, 2Escola Nacional de Saúde Pública - ENSP/UNL, Lisboa, Portugal
A mortalidade infantil (MI) é um problema que afeta o desenvolvimento social e econômico dos países. No Brasil a MI ainda é uma prioridade de Saúde Pública. Houve de facto uma forte diminuição desta mortalidade, que acompanhou o desenvolvimento económico, mas é possível que estes ganhos não tenham sido igualmente distribuídos no território. Objetivo: Este estudo pretende avaliar as desigualdades socioeconómicas nas taxas de mortalidade infantil (TMI) no Estado da Bahia, um dos mais desfavorecidos do país. Métodos: Foi utilizada a base de dados fornecida pelo Sistema de Informação sobre Mortalidade – SIM e de Nascidos Vivos – SINASC para cálculo das TMI municipais para os anos 2000 e 2010 e dos Censos Demográficos do mesmo período. Foi analisada a correlação entre MI a 1 ano e a 5 anos e o rendimento mediano, a taxa de analfabetismo e de saneamento dos municípios, através do teste de Spearman. Resultados: Obtiveram-se diferenças entre as taxas de mortalidade em menores de 1 ano e de 5 anos no ano de 2000 quando relacionadas a taxa de saneamento (p=0,010) e (p=0,011) e a taxa de analfabetismo (p=0,004) e (p=0,004), todas mostrando associações fracas (inferior a 0.2). Para as variáveis rendimento médio e mediano nos anos 2000 e 2010, assim como para a taxa de saneamento e de analfabetismo em 2010, não se encontraram diferenças significativas. Conclusão: Estes achados indicam que outros fatores estiveram associados à queda da mortalidade infantil, e que outros estudos são necessários.
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Primary care user's voice in Portugal – did patient satisfaction changed with the new organizational models?
Pedro Lopes Ferreira1,2, Vítor Raposo1,2,3 1Centre of Health Studies and Research of the University of Coimbra (CEISUC), Coimbra, Portugal, 2Faculty of Economics of the University of Coimbra (FEUC), Coimbra, Portugal, 3Centre for Business and Economics Research (CeBER), Coimbra, Portugal
AIM: In Portugal, primary care is the first and the main form of citizens’ contact with the health system. Our objective is to determine the degree of user satisfaction with the care provided; identify the determinants of primary-care user’s satisfaction and possible asymmetries; compare the most recent results (2015) with preview survey (2009).
METHODS: A EUROPEP based questionnaire applied, during 2015, in 444 primary-care units with different organizational models in the five Portuguese healthcare-regions; 58,846 questionnaires distributed to users in a one-day census sample. The main dimensions measured were medical care (interpersonal and technical components),
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non-medical care (nurses and staff), organization (accessibility and the general services provided), and quality of facilities.
RESULTS: A total response-rate of 89.4%. Global satisfaction of 77,8%. Women showed a slightly lower satisfaction than that of men; the same happening to young people facing the elderly; people with less educational qualifications presented best ratings. Satisfaction asymmetries among organizational models and regions. Related 2009, there was an increase in satisfaction in all regions, only in the North, Centre and Lisbon and Tagus Valley those increases are statistically significant.
CONCLUSION: In spite of an improvement regarding last survey (2009), we have noticed a great disparity of satisfaction indices by health regions and, within each, by primary-care unit. The results point to the need to invest in the creation of more USF units. Policy makers/government have challenge of balancing the incentives to attract/encourage professionals from traditional-model to the USF model and the budget and fiscal constraints.
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Satisfação profissional dos Médicos de Anatomia Patológica em Portugal.
Domingos Oliveira1, Pedro Ferreira2 1Instituto Português de Oncologia de Coimbra Francisco Gentil, E.P.E., Coimbra, Portugal, 2Centro de Estudos e Investigação em Saúde da Universidade de Coimbra, Coimbra, Portugal
Introdução: Vários são os trabalhos publicados que abordam a satisfação profissional dos médicos. No entanto, em Anatomia Patológica, os trabalhos incidem mais sobre a satisfação dos utilizadores.
Objetivos: Determinar a satisfação profissional dos médicos de Anatomia Patológica em Portugal.
Métodos: Estudo observacional e transversal, com análise descritivo-correlacional. A recolha de dados foi realizada através do Instrumento de Avaliação da Satisfação Profissional, ao qual foram acrescentadas perguntas de um inquérito da Sociedade Espanhola desta Área, com preenchimento eletrónico.
Resultados: A amostra correspondeu a 62 profissionais (taxa de resposta de 28,6%).
O nível médio de satisfação foi de 64,6%. A satisfação com os Serviços, como local de trabalho foi de 62,3%, com a qualidade dos serviços prestados foi de 70,3% e com a melhoria contínua da qualidade foi de 68,6%.
96,4% recomendariam o seu Serviço a familiares/ amigos e 96,4% recorreriam eles próprios ao seu Serviço caso necessitassem. Se pudessem voltar atrás, 74,5% escolheriam de novo o seu Serviço e 12,9% não voltaria a escolher esta Especialidade.
Conclusões: Recomenda-se uma maior sensibilização junto dos profissionais desta Área para a participação neste tipo de estudos, bem como a utilização do indicador da satisfação profissional em possíveis ações de contratualização.
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Monitorização da satisfação dos utilizadores dos cuidados de saúde primários: os últimos 25 anos
Pedro Ferreira, Vítor Raposo CEISUC/FEUC, Coimbra, Portugal
A satisfação dos doentes é uma componente indispensável da avaliação da qualidade de vida, com uma correlação clara com os resultados em saúde. Esta comunicação rever a história da medição da satisfação dos utilizadores dos cuidados de saúde primários (CSP) em Portugal e os ganhos obtidos nos últimos 25 anos.
Todo o processo foi iniciado em 1994 quando um grupo de investigadores submeteu a fundos europeus um projeto que pretendia criar o EuropPEP, um instrumento de medição para avaliar a satisfação dos utilizadores em contexto
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de cuidados primários. Em 2000 houve uma primeira implementação nos então 86 centros de saúde de Lisboa e Vale do Tejo, no ano seguinte em 194 centros de saúde, depois nos 365 centros de saúde e, em 2009, nas 146 USF existentes. Por fim, em 2014/15 foram avaliadas todas as 394 USF em atividade e uma amostra de 51 UCSP. Novo estudo está presentemente a ser preparado abrangendo todas as unidades funcionais (UCSP e USF) de cuidados de saúde primários.
Estes estudos têm permitido a criação de informação estratégica relevante à avaliação dos vários modelos de prestação de cuidados de saúde primários e a sua integração na contratualização externa com estas unidades, assim como na definição de políticas de saúde. É urgente uma medição sistemática da satisfação de utilizadores dos cuidados e saúde primários.
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SESSÃO POSTERS B
Determinantes socioeconômicos e ambientais na incidência e mortalidade por câncer de mama: análise cienciométrica, 2006 - 2016
Cássia Kely Favoretto Costa1, Olívia Takahashi Margarido2, Ednaldo Michellon1 1Docente do Programa de Pós-Graduação em Ciências Econômicas da Universidade Estadual de Maringá (UEM), Maringá, Brazil, 2Mestranda em Ciências Econômicas da Universidade Estadual de Maringá (UEM), Maringá, Brazil
O presente artigo tem como objetivo verificar quais são os fatores socioeconômicos e ambientas que estão associados à incidência e mortalidade por câncer de mama nos diversos países. Para tanto, foi realizada uma revisão cienciométrica nas publicações das bases MEDLINE, LILACS, dentre outras, incluídas na Biblioteca Virtual em Saúde, no período de 2006 a 2016. As palavras-chave utilizadas na pesquisa foram BREAST CANCER e SOCIOECONOMIC FACTORS, BREAST CANCER e AMBIENTAL FACTORS e, por fim, BREAST CANCER e PESTICIDES. Foram selecionadas 34 publicações a serem mais bem estudadas, sendo 14 tratando da associação entre câncer de mama e fatores socioeconômicos, 12 da associação com fatores ambientais e 8 da associação com agrotóxicos. Associação positiva entre maior status socioeconômico e incidência de câncer de mama foi constatada em três artigos, sendo mediada pelas diferenças na exposição a fatores reprodutivos e ingestão de álcool. Associação positiva entre menor status socioeconômico e taxa de mortalidade foi constatada em oito artigos, sendo atribuídas principalmente às disparidades no acesso aos serviços de saúde e menor informação quanto à prevenção do câncer de mama. Associação positiva entre fatores ambientais (tabagismo, exposição ao cádmio e poluição do ar) e o câncer de mama, foi observada em sete dos 12 artigos selecionados. Em particular, o efeito que os agrotóxicos têm sobre o risco de desenvolvimento do câncer de mama foi encontrado em metade dos oito artigos. Conclui-se que estratégias públicas deveriam ser melhores direcionadas para reduzir a mortalidade pela doença, com foco principal no diagnóstico precoce da doença.
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O impacto da arrecadação municipal e das transferências estaduais sobre o Índice de Desenvolvimento Humano (Longevidade) dos municípios paranaenses (2000-2010)
Kézia Bondezan, Gabrielle Garcia Universidade Estadual de Maringá, Maringá, Brazil
O trabalho realizou um teste empírico para verificar o impacto da arrecadação municipal (medida pelos impostos e pelas transferências estaduais), sobre o Índice de Desenvolvimento Humano Municipal- Longevidade. O modelo utilizado na regressão dos dados foi o de dados em painel para os municípios do estado do Paraná nos anos 2000 e 2010.Os dados coletados para a análise, mostram que entre os anos de 2000 à 2010, proporção da população da população paranaense apresentou evolução na qualidade de vida. Cerca de 80,59% dos municípios em 2000 estava em um patamar de classificação entre 0,500 à 0,6500 e saltou em 2010 para um patamar acima entre 0,650 à 0,800 (90,16%), isso mostra que a esperança de vida ao nascer tem evoluído de forma positiva ao longo do tempo. Através da regressão econométrica em Dados de Painel, foi possível verificar dentre os fatores que condicionam e influenciam o índice de longevidade, as variáveis fiscais de arrecadação dos municípios do Paraná tiveram impacto no desenvolvimento municipal. O Imposto Predial e Territorial Urbano (IPTU) foi a arrecadação que mais impactou o IDM-M (Longevidade), obtendo o valor de 0.00919 sobre o índice, em seguida as Transferências Estaduais correntes (0.0374), as taxas municipais (0.0325) e os Impostos Sobre Serviços (ISS), com o valor de (0.00237). Esses valores mostram a importância da arrecadação municipal e também das transferências estaduais como forma de melhorar a qualidade de vida da população. Além das variáveis contábeis, sugere-se também que o resultado dependa de variáveis não contábeis, tais como um planejamento público eficiente que visem a elaboração de políticas públicas eficazes, que deverão ainda ser acrescentadas
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PERFIL DE MORBIDADE, GASTOS E PERMANÊNCIA HOSPITALAR POR ACIDENTES DE TRÂNSITO COM MOTOCICLISTAS NO PARANÁ, BRASIL
Marina Magalhães Camora1, Cássia Kely Favoretto Costa2, Eraldo Schunk da Silva3, Marcos Brambilla4, Ely Mitie Massuda5 1Universidade Estadual de Maringá, Maringá, Paraná, Brazil, 2Programa de Pós Graduação em Economia, Departamento de Economia, Universidade Estadual de Maringá, Maringá, Paraná, Brazil, 3Programa de Pós Graduação em Estatística, Departamento de Estatística, Universidade Estadual de Maringá, Maringá, Paraná, Brazil, 4Programa de Pós Graduação em Economia, Universidade Estadual de Maringá, Maringá, Paraná, Brazil, 5Programa de Pós Graduação em Promoção da Saúde, Centro Universitário de Maringá, Maringá, Paraná, Brazil
OBJETIVO: analisar o comportamento das morbidades, gastos e permanência hospitalar por acidentes de trânsito com motociclistas em relação aos aspectos econômicos e demográficos do Paraná, Brasil. MÉTODO: Utilizou-se a técnica multivariada de Análise Fatorial e de Agrupamento (Cluster). As variáveis consideradas foram: a) taxa de motorização de motocicletas; b) Produto Interno Bruto per capita; c) dias de permanência hospitalar; d) custos com internações e e) internações hospitalares do Sistema Único de Saúde por essa causa. O período de análise foi de 2010 até 2013. A área de abrangência correspondeu as 22 regionais de saúde do estado.
RESULTADOS: No período analisado foram realizadas 10.245 internações, as quais geraram um custo de 15.395,00 milhões de reais para o SUS no estado. As regionais de saúde com maior desenvolvimento econômico, bem como aquelas classificadas com nível intermediário, apresentaram alta prevalência de internações, dos custos e do tempo de permanência relativos aos acidentes com motociclistas. A taxa de motorização de motocicletas nessas áreas foram as mais altas quando comparadas as regiões de desenvolvimento econômico menor.
CONCLUSÃO: Existem disparidades no perfil das morbidades, gastos e tempo de permanência hospitalar por esse agravo em função das condições econômicas e demográficas do Paraná. Considerando o crescente número de acidentes de trânsito com motociclistas, é necessário a implantação de políticas públicas mais eficientes, principalmente de educação e fiscalização no trânsito, a fim de reduzir esse número e, consequentemente, minimizar esse problema de saúde pública para as vítimas, o governo e a sociedade em geral dessas áreas geográficas.
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High effectiveness and clinical safety with daclatasvir in real-life
Ana Morbey1, Cristina Valente2, Fátima Serejo3, Rui Tato Marinho3, Rui Sarmento e Castro4, Alexandra Martins5, Isabel Pedroto4, Armando Carvalho2, Paula Peixe6, Fernando Maltez1, José Velosa3, Catarina Silva7,8, Miguel Faria7 1Hospital Curry Cabral, Lisbon, Portugal, 2Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, 3Hospital Santa Maria, Lisbon, Portugal, 4Hospital de Santo António, Porto, Portugal, 5Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal, 6Hospital de Egas Moniz, Lisbon, Portugal, 7Eurotrials, Scientific Consultants, Lisbon, Portugal, 8CISP, Lisbon, Portugal
Background: Real world data is a key issue in chronic hepatitis C (HCV) therapy namely for the evaluation of effectiveness, safety and costs of innovative medicines. We evaluated the effectiveness and safety of daclatasvir-based regimens in the treatment of HCV with direct-acting antivirals (DAAs)-containing regimen.
Material and Methods: Data was obtained from 11 centers in Portugal. We included mono and co-infected HIV/HCV patients, naïve and experimented and pre and post-liver transplanted individuals who initiated
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daclatasvir+sofosbuvir±ribavirin (DCV+SOF±RBV) for 12 or 24 weeks. SVR12 was calculated considering only patients that have completed treatment.
Results: Data from 150 patients who initiated DCV-based regimens was evaluated. Patients were mainly GT3 - 89% (others: 7% GT1a, 1% GT1b and 3% GT4); 14% HIV/HCV co-infected and 26% pre-/post-liver transplanted. Overall, 57% individuals initiated DCV+SOF and 43% DCV+SOF+RBV; 57% and 19% patients had compensated and decompensated cirrhosis, respectively. The global SVR12 was 96%. In 12-week regimens, in GT3 patients, the global SVR12 was 94% with DCV+SOF and 100% with DCV+SOF+RBV. In 24-week treatments, in GT3 patients, the global SVR12 was 97% with DCV+SOF±RBV. SVR12 was 100% in all genotypes pre- and post-liver transplanted patients. All re-treated patients who completed the treatment achieved SVR12. Three patients died. In spite of rare, the most frequent adverse events were headache in those without RBV and fatigue in those with RBV.
Conclusions: These real-life results from patients with advanced liver disease, demonstrated that DCV-based regimens for 12 or 24 weeks are highly effective (in more than 95%) and well tolerated in difficult-to-treat-patients, in pre-/post-liver transplanted and in co-infected individuals.
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Socioeconomic inequalities in the prevalence of multimorbidity in Portugal: results from the fifth National Health Interview Survey 2014
Sónia Romano1,2, Irina Kislaya1,3, Joana Esparteiro1,4, Ausenda Machado1,3 1Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisboa, Portugal, 2Centro de Estudos e Avaliação em Saúde (CEFAR) / Associação Nacional das Farmácias, Lisboa, Portugal, 3Departamento de Epidemiologia / Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal, 4Novartis Farma – Produtos Farmacêuticos S.A./ Departamento de Acesso ao Mercado, Lisboa, Portugal
Background and Objective: Patients with multimorbidity have poor health outcomes, high healthcare utilisation, and increased average cost of care. In Portugal, in a context of severe aging, multimorbidity becomes a major public health concern. This study aims to estimate the prevalence of multimorbidity and quantify the socioeconomic inequalities in the occurrence of multimorbidity in Portuguese population aged 35 years or over.
Methods: Data from the 5th National Health Interview Survey (n=14943) held in 2014 were analyzed. Multimorbidity was defined as self-report of two or more chronic conditions. Participants' socioeconomic status was measured through education and household equivalized disposable income. The relative index of inequality (RII) was estimated to determine the socioeconomic inequalities, controlling for age, occupation, degree of urbanization, and dimension of household. All estimates were weighted to account for complex sample design, and stratified by sex.
Results: The prevalence of multimorbidity in Portuguese population aged 35 years or over, was 42.5% [95%CI: 40.6-44.5] and 60.4% [95%CI: 58.58-62.15] for men and women, respectively. We observed an inverse educational gradient in multimorbidity for both men (RII=1.34, [95%CI:1.12-1.60] and women (RII=1.45, [95%CI:1.30-1.62]). Income-related inequalities were smaller (RII=1.25, [95%CI: 1.08-1.45] for men, and not significant for women (RII=1.02, [95%CI:0.94-1.1]).
Discussion and Conclusion(s): In addition to be highly prevalent, multimorbidity is unequally distributed in the Portuguese population, being more frequent amongst the less educated men and women, and amongst the poorer men. Future public health policies and interventions should take in considerations this socioeconomic patterning.
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Equidade na prestação e financiamento em saúde
Marta Frias Borges1,2, Filomena Girão1,2, Carlos Costa Gomes1 1Instituto de Bioética - Universidade Católica Portuguesa, Porto, Portugal, 2FAF Advogados, Coimbra, Portugal
Objectivo: Análise da contribuição dos normativos legais para a prossecução da equidade em saúde.
Método: Revisão e estudo dos textos legais vigentes relativos aos cuidados em saúde e dos indicadores recentes de saúde.
Resultados: O direito à protecção da saúde tem consagração constitucional. Enquanto direito social típico, este direito reclama uma prestação do Estado para a sua realização, nomeadamente através da criação e sustentação de um Serviço Nacional de Saúde universal, geral e tendencialmente gratuito. Sucede que o aumento da esperança média de vida, conjugado com os avanços tecnológicos e científicos, e a ausência de monitorização e avaliação das políticas de saúde, justificam a ineficácia destas e o aumento dos custos da prestação de cuidados de saúde. Assim, a bem da sustentabilidade do SNS, impõe-se uma reflexão cuidada sobre a equidade no acesso e no financiamento dos cuidados de saúde, uma vez que a efectiva prossecução do direito à saúde obriga a uma criteriosa gestão daqueles recursos. Importa garantir a todos os cidadãos a realização de uma justiça equitativa no acesso aos cuidados de saúde, que assegure a diferença e a “distinção" como forma de beneficiar os mais desfavorecidos, numa concepção de justiça igualitária.
Conclusões: Para garantir a sustentabilidade do SNS e a sua efectiva equidade, importa alterar diversas disposições legislativas, à luz de uma bioética personalista, que assegure a realização da tão almejada equidade, designadamente com a introdução de taxas moderadoras progressivas, com a reutilização de alguns bens e, mesmo, com a modalidade de co-pagamento nalguns bens e serviços.
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Weekend effect no setor hospitalar brasileiro: o caso de infarto agudo do miocárdio
Pedro Henrique Soares Leivas1, Paulo de Andrade Jacinto2, Anderson Moreira Aristides dos Santos3, César Augusto Oviedo Tejada4 1PUC/RS, Porto Alegre, Brazil, 2UFPR, Curitiba, Brazil, 3UFAL, Maceió, Brazil, 4UFPEL, Pelotas, Brazil
Objetivo (Objective): investigar a existência do weekend effect no setor hospitalar brasileiro.
Metodologia (Methodology): Os dados utilizados são provenientes do Sistema de Informações Hospitalares e do Cadastro Nacional de Estabelecimentos de Saúde, do Sistema Único de Saúde e compreendem o período de 2008 a 2014. O outcome dos pacientes foi avaliado pela mortalidade intra-hospitalar. Os controles compreendem características dos pacientes (idade, sexo, procedimento realizado, tempo de permanência, utilização de UTI, e índice de comorbidade de Charlson), dos hospitais (tempo médio de permanência dos pacientes, número de leitos, número de pacientes atendidos e efeito fixo de hospital) e dos municípios onde os pacientes residem (população). Foram calculadas razoes de chances brutas e ajustadas por meio de regressão logística.
Resultados (Results): Os resultados evidenciam a existência de um weekend effect no setor hospitalar brasileiro que se mantém mesmo após o controle de uma série de fatores, inclusive efeito fixo de hospital.
Conclusões (Conclusions): Certamente um dos canais através do qual ocorre o weekend effect é a redução acentuada do staff hospitalar durante os finais de semana. Nesse sentido, aumentar a quantidade de recursos humanos nos hospitais aos finais de semana pode ajudar a mitigar a maior chance de óbito durante esse período da semana. As
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questões relacionadas aos recursos financeiros, bem como a análise de custo-efetividade desse aumento são questões que precisam ser investigadas.
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Intervenção coronária percutânea em hospitais especializados e hospitais gerais: uma análise empírica para o Brasil
Pedro Henrique Soares Leivas1, Paulo de Andrade Jacinto2, Anderson Moreira Aristides dos Santos3, César Augusto Oviedo Tejada4 1PUC/RS, Porto Alegre, Brazil, 2UFPR, Curitiba, Brazil, 3UFAL, Maceió, Brazil, 4UFPEL, Pelotas, Brazil
Objetivo (Objective): avaliar o impacto de o paciente ter sido submetido a Intervenção Coronária Percutânea (ICP) em hospital especializado sobre a probabilidade de óbito.
Metodologia (Methodology): Os dados utilizados são provenientes do Sistema de Informações Hospitalares e do Cadastro Nacional de Estabelecimentos de Saúde, do Sistema Único de Saúde e compreendem o período de 2008 a 2014. O outcome dos pacientes foi avaliado pela mortalidade intra-hospitalar. Os controles compreendem características dos pacientes, dos hospitais e dos municípios onde os pacientes residem. Para contornar a endogeneidade do volume e da variável que indica hospital especializado, empregamos um Modelo de Variáveis Instrumentais, em que as mesmas foram instrumentalizadas por duas variáveis construídas explorando a distribuição geográfica dos pacientes e dos hospitais. O instrumento do volume foi o volume esperado e o instrumento da variável de hospital especializado foi a distância diferencial, que corresponde à diferença entre a distância da residência do paciente até o hospital especializado mais próximo e a distância entre a residência do paciente e o hospital geral mais próximo.
Resultados (Results): Os resultados sugerem que os pacientes dos hospitais especializados têm pior estado de saúde do que os dos hospitais gerais. Ao controlar uma série de fatores e buscar mitigar o problema de endogeneidade do modelo, evidencia-se que a probabilidade de óbito é menor quando o paciente é submetido a ICP em hospital especializado.
Conclusões (Conclusions): Diante dos resultados apresentados no trabalho, o aumento da oferta de hospitais especializados poderia acarretar em resultados melhores para os pacientes.
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Sistemas de notificação de dispositivos médicos inovadores na área da diabetes - o caso português
Vânia Sousa, Paula Benesch, Maria Olívia Pereira Universidade do Minho, Braga, Portugal
Os sistemas de identificação e notificação de tecnologias de saúde novas ou em desenvolvimento (Early Awareness and Alert- EAA) podem ser usados como parte de um sistema nacional de Health Technology Assessment (HTA) para identificar e filtrar tecnologias que têm potenciais implicações para um serviço de saúde, tendo em consideração os seus benefícios clínicos e custos, permitindo que financiadores e decisores políticos possam ter informação atempada antes da sua adoção. Existem várias fontes de informação e ferramentas que podem ser incluídas num sistema, que pode ser de natureza ativa, passiva ou uma combinação de ambos. Este trabalho tem como objetivo desenvolver um sistema de EAA no INFARMED, I.P., com base numa combinação de notificação e identificação ativa (atravéns de um protocolo de pesquisa web) e passiva (através da submissão pública de propostas para avaliação). Este sistema foi desenvolvido com foco numa área definida como prioritária pelo Plano Nacional de Saúde: a diabetes. O protocolo foi criado e aplicado especificamente a dispositivos médicos que entrarão no mercado até 5 anos e foram incluídas fontes, termos-chave, frequência de uso, entre outros parâmetros. A plataforma foi desenvolvida e implementada para
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que distintos stakeholders, que têm muitas vezes um acesso muito precoce e privilegiado à informação, possam partilhar facilmente a mesma com o INFARMED, I.P.. Os resultados mostram que as duas ferramentas são fáceis de implementar e monitorizar distintos grupos de dispositivos na área em diferentes fases de desenvolvimento, com poucos recursos, sendo vantajosa a sua utilização para efeitos de adoção e/ou financiamento.
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Notas/Notes
