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- Embolia pulmonar em Portugal: epidemiologia e mortalidade intra-hospitalarPublication . Gouveia, Miguel; Pinheiro, Luís; Costa, João; Borges, MargaridaIntrodução: Em Portugal, a epidemiologia da embolia pulmonar aguda é mal conhecida. Neste estudo, pretendeu-se caracterizar aembolia pulmonar a partir dos dados do internamento hospitalar, assim como avaliar a sua mortalidade intra-hospitalar (definida como mortalidade do internamento hospitalar) e respetivos fatores de prognóstico. Material e Métodos: Microdados dos Grupos de Diagnóstico Homogéneo dos hospitais do Sistema Nacional de Saúde (2003 a 2013)e dados sobre população do Instituto Nacional de Estatística para estabelecer a evolução dos internamentos, da mortalidade intra-hospitalar e das taxas de incidência na população. Os microdados foram estudados numa regressão logit modelizando a mortalidade intra-hospitalar como função de características individuais e de variáveis de contexto. Resultados: Entre 2003 e 2013 ocorreram 35 200 episódios de internamento (doentes ≥ 18 anos) em que pelo menos um dos diagnósticos foi embolia pulmonar (diagnóstico principal em 67% dos casos). A taxa de incidência estimada em 2013 foi 35/100 000-habitantes (≥ 18 anos). Entre 2003 e 2013, o número anual de episódios foi aumentando, mas a taxa de mortalidade intra-hospitalar foi diminuindo (de 31,8% para 17% em todos os episódios e de 25% para 11,2% nos episódio com embolia pulmonar como diagnóstico principal). Entre 2010 e 2013 a probabilidade de morte reduziu-se com a existência de registo de tomografia computorizada, em doentes do género feminino e aumentou com a idade e a presença de comorbilidades. Discussão: Na última década ocorreu um aumento da incidência de embolia pulmonar provavelmente relacionado com um maior número de pessoas dependentes e acamadas. No entanto, verificou-se uma redução da mortalidade intra-hospitalar de tal dimensão que a própria taxa de mortalidade na população em geral se reduziu. Uma explicação possível é que tenha ocorrido um aumento dos episódios de embolia pulmonar com níveis de gravidade incrementalmente menores, pela maior capacidade de diagnóstico de casos menos graves. Outra explicação possível é uma maior efetividade dos cuidados de saúde hospitalares. De acordo com a análise de regressão logística, as melhorias na efetividade dos cuidados hospitalares nos últimos anos são o principal responsável pela redução da mortalidade. Conclusão: Cerca de 79% da redução da mortalidade intra-hospitalar da embolia pulmonar entre 2003 e 2013 pode-se atribuir à maior efetividade dos cuidados de saúde hospitalares e o restante à alteração favorável nas características dos doentes associadas ao risco de morte.
- The impact of osteoarthritis on early exit from work: results from a population-based studyPublication . Laires, Pedro A.; Canhão, Helena; Rodrigues, Ana M.; Eusébio, Mónica; Gouveia, Miguel; Branco, Jaime C.Background: Osteoarthritis (OA) is a leading cause of pain and disability, which may be a source of productivity losses. The objectives of this study were to describe the impact of OA, namely through pain and physical disability, on early exit from work and to calculate its economic burden. Methods: We analysed data from the national, cross-sectional, population-based EpiReumaPt study (Sep2011-Dec2013) in which 10,661 individuals were randomly surveyed in order to capture all cases of rheumatic diseases. We used all participants aged 50-64, near the official retirement age, who were clinically validated by experienced rheumatologists (n = 1286), including OA cases. A national database was used to calculate productivity values by gender, age and region, using the human capital approach. The impact of OA on the likelihood of early exit from work and the population attributable fractions used to calculate due economic burden (indirect costs) were obtained at the individual level by logistic regression. All results were based on weighted data. Results: Almost one third of the Portuguese population aged 50-64 had OA (29.7%; men: 16.2% and women: 43.5%) and more than half were out of paid work (51.8%). Only knee OA is associated with early exit from work (OR: 2.25; 95%CI: 1.42-3.59; p = 0.001), whereas other OA locations did not reach any statistical difference. Furthermore, we observed an association between self-reported longstanding musculoskeletal pain (OR: 1.55; 95%CI: 1.07-2.23; p = 0.02) and pain interference (OR: 1.35; 95%CI: 1.13-1.62; p = 0.001) with early exit from work. We also detected a clear relationship between levels of disability, measured by the Health Assessment Questionnaire (HAQ), and the probability of work withdrawal. The estimated annual cost of early exit from work attributable to OA was €656 million (€384 per capita; €1294 per OA patient and €2095 per OA patient out-of-work). Conclusions: In this study, we observed an association between OA and early exit from work, largely dependent on pain and disability. This relationship translates into a meaningful economic burden amounting to approximately 0.4% of the national Gross Domestic Product (GDP). The high prevalence and the impact of this disabling chronic disease highlight the need to prioritize policies targeting early exit from work in OA.
- The current and future burden of heart failure in PortugalPublication . Gouveia, Miguel; Ascenção, Raquel; Fiorentino, Francesca; Costa, João; Caldeira, Daniel; Broeiro-Gonçalves, Paula; Fonseca, Candida; Borges, MargaridaAims: Heart failure (HF) is a clinical syndrome with significant social and economic burden. We aimed to estimate the burden of HF in mainland Portugal over a 22-year time horizon, between 2014 and 2036. Methods and results: Heart failure burden was measured in disability-adjusted life years (DALYs), resulting from the sum of years of life lost (YLL) due to premature death and years lost due to disability (YLD). YLL were estimated based on the Portuguese mortality rates reported by the European Detailed Mortality Database. For YLD, disease duration and the overall incidence were estimated using an epidemiological model developed by the World Health Organization (DISMOD II). Disability weights were retrieved from published literature. The impact of ageing was estimated with a shift-share analysis using official demographic projections. In 2014, 4688 deaths were attributed to HF, corresponding to 4.7% of the total deaths in mainland Portugal. DALYs totalled 21 162, 53.9% due to premature death (YLL: 11 398) and 46.1% due to disability (YLD: 9765). Considering only population ageing over a 22-year horizon, the deaths and burden of HF are expected to increase by 73.0% and 27.9%, respectively, reaching 8112 deaths and 27 059 DALYs lost due to HF in 2036. DALY's growth is mainly driven by the increase of YLL, whose contribution to overall burden will increase to 62.0%. Conclusions: Heart failure is an emerging and growing health problem where significant health gains may be obtained. The projected significant increase of HF burden highlights the need to set HF as a priority for healthcare system.
- The burden of atherosclerosis in PortugalPublication . Costa, João; Alarcão, Joana; Araujo, Francisco; Ascenção, Raquel; Caldeira, Daniel; Fiorentino, Francesca; Gil, Victor; Gouveia, Miguel; Lourenço, Francisco; Silva, Alberto Mello E; Sampaio, Filipa; Carneiro, António Vaz; Borges, MargaridaAIMS: This article sought to estimate the burden of disease attributable to atherosclerosis in mainland Portugal in 2016. METHODS AND RESULTS: The burden of atherosclerosis was measured in disability-adjusted life years following the latest 2010 Global Burden of Disease (GBD) methodology. Disability-adjusted life years were estimated as the sum of years of life lost (YLL) with years lived with disability (YLD). The following clinical manifestations of atherosclerosis were included: ischaemic heart disease (IHD) (including acute myocardial infarction, stable angina, and ischaemic heart failure), ischaemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD). Years of life lost were estimated based on all-cause mortality data for the Portuguese population and mortality due to IHD, ICVD, and PAD for the year 2016 sourced from national statistics. Standard life expectancy was sourced from the GBD study. Years lived with disability corresponded to the product of the number of prevalent cases by an average disability weight for all possible combinations of disease. Prevalence data for the different clinical manifestations of atherosclerosis were sourced from epidemiological studies. Disability weights were sourced from the published literature. In 2016, 15 123 deaths were attributable to atherosclerosis, which corresponded to 14.3% of overall mortality in mainland Portugal. Disability-adjusted life years totalled 260 943, 75% due to premature death (196 438 YLL) and 25% due to disability (64 505 YLD). CONCLUSION: Atherosclerosis entails a high disease burden to society. A large part of this burden would be avoidable if evidence-based effective and cost-effective interventions targeting known risk factors, from prevention to treatment, were implemented.
- Custos indiretos associados a eventos cardiovasculares em PortugalPublication . Gouveia, Miguel
- Os custos da aterosclerose em PortugalPublication . Costa, João; Alarcão, Joana; Amaral‐Silva, Alexandre; Araújo, Francisco; Ascenção, Raquel; Caldeira, Daniel; Cardoso, Marta Ferreira; Correia, Manuel; Fiorentino, Francesca; Gavina, Cristina; Gil, Victor; Gouveia, Miguel; Lourenço, Francisco; Silva, Alberto Mello e; Pedro, Luís Mendes; Morais, João; Vaz‐Carneiro, António; Veríssimo, Manuel Teixeira; Borges, MargaridaIntroduction and objectives: Cardiovascular disease is the leading cause of death in Portugal and atherosclerosis is the most common underlying pathophysiological process. The aim of this study was to quantify the economic impact of atherosclerosis in Portugal by estimating disease‐related costs. Methods: Costs were estimated based on a prevalence approach and following a societal perspective. Three national epidemiological sources were used to estimate the prevalence of the main clinical manifestations of atherosclerosis. The annual costs of atherosclerosis included both direct costs (resource consumption) and indirect costs (impact on population productivity). These costs were estimated for 2016, based on data from the Hospital Morbidity Database, the health care database (SIARS) of the Regional Health Administration of Lisbon and Tagus Valley including real‐world data from primary care, the 2014 National Health Interview Survey, and expert opinion. Results: The total cost of atherosclerosis in 2016 reached 1.9 billion euros (58% and 42% of which was direct and indirect costs, respectively). Most of the direct costs were associated with primary care (55%), followed by hospital outpatient care (27%) and hospitalizations (18%). Indirect costs were mainly driven by early exit from the labor force (91%). Conclusions: Atherosclerosis has a major economic impact, being responsible for health expenditure equivalent to 1% of Portuguese gross domestic product and 11% of current health expenditure in 2016.
- Os custos da insuficiência cardíaca em Portugal e a sua evolução previsível com o envelhecimento da populaçãoPublication . Gouveia, Miguel Rebordão de Almeida; Ascenção, Raquel Maria Sousa e Silva; Fiorentino, Francesca; Costa, João Nuno Marques Parracho Guerra da; Broeiro‐Gonçalves, Paula Maria; Fonseca, Maria Cândida Faustino Gamito da; Borges, Margarida de Fátima Palma FeriaIntrodução e objetivos: A insuficiência cardíaca (IC) é um problema crescente de saúde pública. Este estudo estima os custos atuais e futuros da IC em Portugal Continental. Métodos: A estimativa dos custos foi realizada na ótica da prevalência e na perspetiva da sociedade. Os custos anuais da IC incluíram os custos diretos (consumos de recursos) e indiretos (impacto na produtividade da população). Utilizaram‐se maioritariamente dados da Base de Dados de Morbilidade Hospitalar, dados da prática clínica real relativamente aos consumos nos cuidados primários e opiniões de peritos. Estimaram‐se os custos para 2014 e, tendo em conta o envelhecimento da população, a evolução dos mesmos até 2036. Resultados: Os custos diretos em 2014 totalizaram €299 milhões (39% por internamentos, 24% por medicamentos, 17% por meios complementares de diagnóstico e terapêutica, 16% por consultas e o restante por outras rubricas como urgências e cuidados continuados). Os custos indiretos totalizaram €106 milhões (16% por absenteísmo e 84% por redução de emprego). Entre 2014 e 2036, por efeitos demográficos, os custos totais passarão de €405 para €503 milhões. O aumento nos custos por habitante será de 34%, um aumento superior ao dos custos totais (+ 24%) dada a redução prevista da população residente. Conclusões: A IC tem um importante impacto económico atual (2,6% do total das despesas públicas em saúde) e previsivelmente maior no futuro, o qual deve ser tido em consideração pelos responsáveis pelas políticas de saúde por forma a adequar a gestão de recursos atual e futura e minimizar o impacto desta doença.
- Indirect costs of myocardial infarction in PortugalPublication . Timóteo, Ana Teresa; Gouveia, Miguel; Soares, Cristina; Ferreira, Rui CruzIntroduction: Cardiovascular disease, and particularly myocardial infarction (MI), carries a significant economic burden, through productivity losses (indirect costs) associated with temporary absence from work, that has not yet been adequately studied in Portugal. Our objective was to quantify the indirect costs of MI in the first year after admission. Methods: Consecutive patients admitted to a single center aged <66 years who survived to discharge during a one-year period were included. Employment status on admission was assessed and for every employed patient, their monthly wage was estimated from market wage rates taken from the Ministry of Labor database according to gender and age. The duration of temporary absence from work was assessed in follow-up contacts for up to one year. Indirect costs were calculated in this sample and the results were applied to the number of MIs in Portugal during 2016 and separately to ST-elevation MI (STEMI) and non-ST-elevation acute coronary syndrome. Results: A total of 219 patients were included, of whom 66.2% were working. The mean monthly labor cost was 1802 euros. A total cost of 760 521.55 euros was obtained. At national level there were 4133 patients aged <66 years admitted with acute MI who survived to discharge. Costs were higher in STEMI patients and the total indirect cost was estimated at 10.12 million euros. Conclusions: In Portugal, the costs to society of disability-generated productivity losses exceed ten million euros in the first year after MI. Strategies to promote an earlier return to work are needed to lower these costs.
- Interventions aiming to reduce early retirement due to rheumatic diseasesPublication . Laires, Pedro; Gouveia, M.; Canhão, H.Introduction: Aging of the population and early retirement translates into productivity losses to society. Persistence of working life is crucial to counteract this sustainability issue faced by western countries. Musculoskeletal and rheumatic diseases (RD) may cause work disability and early exit from work, including early retirement. The objective of this article is to review the current knowledge about interventions aiming to reduce early retirement due to RD. Methods:We searched PubMed and The Cochrane Library for studies either in English or Portuguese between January 2000 and June 2016 that evaluated the impact of interventions targeting early retirement in RD patients still at work. We also searched for grey literature from Portuguese institutional repositories. Results: We identified several published studies tes - ting pharmacologic and non-pharmacologic vocatio - nal rehabilitation interventions. None was specifically identified for Portugal. The general low quality of the literature and its inconsistency makes it unfeasible to draw definitive conclusions. However, some broad re - commendations might be outlined. An effective intervention must: 1) act upon different levels (e.g. RD patient, workplace), involving several stakeholders (e.g. rheumatologists, occupational physicians, employers); 2) prioritize the right patients (e.g. more disabling RD); and 3) consider the patients' role, for instance by including an element of patient education and support. Despite the lack of good quality evidence on this field, there seems to be a growing interest in the internatio - nal scientific community with several ongoing studies promoting such interventions. This promising data will be very useful to set up effective policies. Conclusions: This article summarizes the current knowledge about the impact of interventions to avoid or mitigate early retirement in RD patients. It highlights the demand for further research and it also contributes to aware decision-makers about the relevance of this topic, particularly in Portugal.
- Custo-efetividade dos novos anticoagulantes orais na fibrilhação auricular em PortugalPublication . Costa, João; Fiorentino, Francesca; Caldeira, Daniel; Inês, Mónica; Pereira, Catarina Lopes; Pinheiro, Luís; Vaz-Carneiro, António; Borges, Margarida; Gouveia, MiguelIntrodução e objetivos: Os non-vitamin K antagonist oral anticoagulants (NOAC) foram recentemente comparticipados para a fibrilhação auricular não-valvular (FA), sendo relevante determinar o seu custo-efetividade para a realidade portuguesa. Métodos: Foi especificado um modelo Markov para simular a progressão dos doentes com FA no decurso da sua vida. Os dados de efetividade relativa para os eventos acidente vascular cerebral (isquémico e hemorrágico), hemorragia (intracraniana, outras hemorragias major ehemorragias não-major clinicamente relevantes), enfarte agudo do miocárdio e descontinuação do tratamento foram obtidos por comparações indiretas entre o apixabano, o dabigatrano e orivaroxabano (comparador comum: varfarina). As fontes dos dados de consumo de recursos de saúde foram a base de dados dos grupos de diagnóstico homogéneo e painel de peritos. Estimou-se os anos de vida ganhos, anos de vida ajustados pela qualidade (QALY), custos diretos e rácios de custo-efetividade incremental (ICER). Resultados: Os anos de vida ganhos e os QALY foram maiores com apixabano, com um ICER versus varfarina e dabigatrano de 5529 € /QALY e 9163 € /QALY, respetivamente. O apixabano foi dominante versus o rivaroxabano (maiores ganhos em saúde e menores custos). Estes resultados foram robustos nas análises de sensibilidade realizadas, tendo o apixabano uma probabilidade de 70% de ser custo-efetivo (threshold: 20 000 € /QALY) versus o conjunto das restantes opções esterapêuticas.