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Objectives To assess the cost-effectiveness of varenicline in comparison to currently funded smoking cessation strategies in Brazil. Methods We modeled the lifetime direct costs and health-related quality of life of a hypothetical cohort of smokers with a single attempt to quit smoking using one of the following: (1) cognitive behavioral therapy (CBT) without any pharmacological intervention, (2) varenicline, (3) bupropion, (4) nicotine replacement therapy (NRT) with transdermal patch, (5) bupropion in combination with NRT transdermal patch, and (6) combined NRT (oral plus transdermal). All drug alternatives were considered with concomitant CBT. The analysis relied on a Markov model based on the Benefits of Smoking Cessation and Outcomes study and used different age and sex categories in the consideration of relative risks and incidence rates of the diseases included in the model. The analysis was conducted from the healthcare system perspective, and a 3% discounting rate for costs and outcomes was applied. Model parameter values were sourced from published literature. Probabilistic and deterministic sensitivity analyses assessed robustness. Results Among the smoking cessation alternatives available in Brazil, varenicline and combined NRT were estimated to have higher effectiveness; varenicline, however, was dominated due to its higher average cost. In the base-case analysis, combined NRT had an incremental gain of 0.25 quality-adjusted life-years (QALYs) in comparison to the second-best option (bupropion in combination with NRT transdermal patch) and an incremental cost-effectiveness ratio of R$2173.47/QALY ($595.45/QALY). Conclusions Combination of oral and transdermal NRT (coupled with CBT) was the most effective smoking cessation option and was 100% cost-effective within a conservative willingness-to-pay threshold.

Background Due to growing expenditures, health systems have been pushed to improve decision-making practices on resource allocation. This study aimed to identify which practices of priority setting and resource allocation (PSRA) have been used in healthcare systems of high-income countries. Methods A scoping literature review (2007–2019) was conducted to map empirical PSRA activities. A two-stage screening process was utilized to identify existing approaches and cluster similar frameworks. That was complemented with a gray literature and horizontal scanning. A narrative synthesis was carried out to make sense of the existing literature and current state of PSRA practices in healthcare. Results One thousand five hundred eighty five references were found in the peer-reviewed literature and 25 papers were selected for full-review. We identified three major types of decision-making framework in PSRA: 1) Program Budgeting and Marginal Analysis (PBMA); 2) Health Technology Assessment (HTA); and 3) Multiple-criteria value assessment. Our narrative synthesis indicates these formal frameworks of priority setting and resource allocation have been mostly implemented in episodic exercises with poor follow-up and evaluation. There seems to be growing interest for explicit robust rationales and ample stakeholder involvement, but that has not been the norm in the process of allocating resources within healthcare systems of high-income countries. Conclusions No single dominate framework for PSRA appeared as the preferred approach across jurisdictions, but common elements exist both in terms of process and structure. Decision-makers worldwide can draw on our work in designing and implementing PSRA processes in their contexts.

The fiscal regime implemented in Brazil with the constitutional amendment 95 (EC-95) of December 2016 froze primary expenditures for 20 years, including healthcare spending. Previous studies have estimated strong negative effects of this policy on the health of Brazilians. Although there has been a constant pressure to repeal EC-95, this policy is unlikely to be changed in the near future. Thus, there is also a need to take actions within its own terms in order to mitigate its harmful consequences on population health. Shedding light on the existing evidence about the impact of austerity on health, the present work discusses how decision-makers can use a formal framework of decision making in priority setting and resource allocation to tackle the amplified budgetary strain. Drawing on principles of Program Budgeting and Marginal Analysis (PBMA), efficiency can be improved by shifting spending from low-value to higher-value areas, avoiding the “across-the-board cut” caused by non-differential consideration of expenditures in a context of mismatched growth of demand and supply of healthcare. By evaluating opportunity costs of investment and disinvestment proposals on the basis of multiple criteria and marginal analysis, the Brazilian public healthcare system could obtain gains in value, achieving better performance and attenuating the relative decline in spending on health brought by an austerity scenario.

As the COVID-19 pandemic progresses, understanding its sustained impact on healthcare access and utilization represents a vital task for decision-makers and health systems. This study investigates how three aspects of health care utilization (i.e., consultations for COVID-19 related symptoms, cancelation of previously scheduled care and hospitalisation in the past 30 days) relate to individual and municipal factors in a nationally-representative sample of Brazilians aged 50 and over.Data were obtained for 6584 participants from the second wave of the Brazilian Longitudinal Study of Ageing (ELSI-Brazil in Portuguese) who were administered supplemental telephone interviews between September and October 2020. Descriptive statistics, bivariate analysis and multivariate analysis using survey-weighted Poisson regression were applied to evaluate all three outcomes of interest (consultation, care cancelation, and hospitalisation). Predicted probabilities were also calculated to understand the overall effect of relevant covariates.Women were 76% less likely to seek care for COVID-19 symptoms (Odds Ratio [OR] = 0.24, 95% Confidence Interval [CI] = 0.10, 0.53) and 82% more likely to have healthcare cancelled due to the pandemic (OR = 1.82, 95% CI = 1.43, 2.33) than men. Those who live in municipalities with low coverage (40%) of community-based primary care (the Family Health Strategy) were more likely (OR = 1.80, 95% CI = 1.00, 3.22) to be hospitalised for any reason in the past 30 days and more likely to experience healthcare cancelation (OR = 1.43, 95% CI = 1.01, 2.02). Living in the Southeast and Midwest regions was associated with 62% and 78%, respectively, lower odds of previously scheduled care being cancelled due to the pandemic, in comparison to the North region (OR = 0.38, 95% CI = 0.21, 0.67, and OR = 0.22, 95% CI = 0.14, 0.36). Living in the Southeast region was associated with over 7.61 higher odds of having sought care for COVID-19-related symptoms, relative to those living in the North (OR = 7.61, 95% CI = 2.16, 26.85).Results highlight the uneven impact of the COVID-19 pandemic on health care utilization between males and females, and across Brazilian municipalities and regions.

Over the last two decades, economic evaluation of health technologies has developed enormously, affirming its importance within the pursuit of efficiency in the management of health care systems. One concern that has been raised with health technology assessment (HTA) has been its operationalization within the realm of decision making. Here, we suggest a mechanism by which HTA can be understood as an input into a broader framework for priority setting and resource allocation. When HTA is seen in this light, topics that at times have had some lack of clarity, such as public engagement and disinvestment, simply become steps in the overall decision-making process.

Background Healthcare spending has grown over the last decades in all developed countries. Making hard choices for investments in a rational, evidence-informed, systematic, transparent and legitimate manner constitutes an important objective. Yet, most scientific work in this area has focused on developing/improving prescriptive approaches for decision making and presenting case studies. The present work aimed to describe existing practices of priority setting and resource allocation (PSRA) within the context of publicly funded health care systems of high-income countries and inform areas for further improvement and research. Methods An online qualitative survey, developed from a theoretical framework, was administered with decision-makers and academics from 18 countries. 450 individuals were invited and 58 participated (13% of response rate). Results We found evidence that resource allocation is still largely carried out based on historical patterns and through ad hoc decisions, despite the widely held understanding that decisions should be based on multiple explicit criteria. Health technology assessment (HTA) was the tool most commonly indicated by respondents as a formal priority setting strategy. Several approaches were reported to have been used, with special emphasis on Program Budgeting and Marginal Analysis (PBMA), but limited evidence exists on their evaluation and routine use. Disinvestment frameworks are still very rare. There is increasing convergence on the use of multiple types of evidence to judge the value of investment options. Conclusions Efforts to establish formal and explicit processes and rationales for decision-making in priority setting and resource allocation have been still rare outside the HTA realm. Our work indicates the need of development/improvement of decision-making frameworks in PSRA that: 1) have well-defined steps; 2) are based on multiple criteria; 3) are capable of assessing the opportunity costs involved; 4) focus on achieving higher value and not just on adoption; 5) engage involved stakeholders and the general public; 6) make good use and appraisal of all evidence available; and 6) emphasize transparency, legitimacy, and fairness.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused over half a million deaths worldwide. Brazil has been particularly impacted, registering more than 1.3 million infections and 57,000 deaths by late June 2020. Aggregate numbers of cases are essential in modeling the epidemic and planning responses; however, more detailed analysis of risk factors associated with SARS-CoV-2 infection are needed. Our study provides an initial examination of characteristics associated with receiving a doctor’s diagnosis of COVID-19 among a nationally representative sample of Brazilians aged 50 and over. Data are derived from the second wave of the Brazilian Longitudinal Study of Aging (ELSI-Brazil) and a telephone follow-up survey to ELSI-Brazil participants, known as the ELSI-COVID-19 initiative. The telephone survey was conducted between 26 May and 8 June 2020. Results show that about 2.4% (n = 70) of the sample reported being told by a doctor they had COVID-19, however, only about half of these individuals (n = 37) reported receiving a diagnostic confirmation from viral testing (RT-PCR). Demographic factors (aged 50-60 years), socioeconomic factors (lower household income), health-related factors (obesity, three or more chronic conditions), and geography (living in the Northern region of the country) were positively associated with reporting a COVID-19 diagnosis. Despite the descriptive and preliminary nature of these findings, results reported here suggest the need for more targeted approaches to enhance personal protection and provide greater viral testing options, especially for older, sicker and more vulnerable adults in Brazil.

Background: Polypharmacy has become an increasingly public health issue as population age and novel drugs are developed. Yet, evidence on low- and middle-income countries (LMIC) is still scarce. Objective: This work aims to estimate the prevalence of polypharmacy among Brazilians aged 50 and over, and investigate associated factors. Methods: A cross-sectional study was conducted using data from the baseline assessment of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a nationally representative study of persons aged 50 years and older (n=9,412). Univariate and bivariate analyses described the sample. Robust Poisson regression was used to estimate prevalence ratios and predict probabilities of polypharmacy. Results: Prevalence of polypharmacy was estimated at 13.5% among older adults in Brazil. Important disparities were observed in regard to gender (16.1% among women and 10.5% among men), race (16.0% among whites and 10.1% among blacks) and geographic region (ranging from 5.1% in the North to 18.7% in the South). The multivariate analysis showed that polypharmacy is associated with various sociodemographic/individual factors (age, gender, race, education, region, health status, body mass index) as well as with several variables of healthcare access/utilization (number of visits, same physician, provider’s knowledge of patient’s medications, gate-keeper, and difficulty managing own medication). Overall, the more utilization of health services, the higher the probability of polypharmacy, after adjusting for all other model covariates. Conclusions: Polypharmacy prevalence is relatively low in Brazil, compared to European countries. After controlling for variables of healthcare need and demographic characteristics, there is still substantial residual variance in polypharmacy prevalence. Policies to identify inappropriate prescribing and reduce regional discrepancies are necessary.

ObjectivesLittle is known about sleeping pills consumption among older adults in low- and middle-income countries. This study investigated the prevalence and factors associated with sleeping pills use among Brazilians aged 50 and over.MethodsA cross-sectional study was conducted using baseline data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a nationally representative study of persons aged 50 years and older (n = 9412). Univariate and bivariate analyses were used to describe the sample. Robust Poisson regression was employed to estimate prevalence ratios and predict probabilities.Key findingsPrevalence of sleeping pills use among older Brazilians was estimated at 16.8%, with considerable disparities related to gender (22.3% among women and 10.3% among men), race/skin colour (19.7% among whites and 11.9% among blacks) and geographic region (ranging from 5.9% in the North to 20.5% in the South). The multivariate analysis showed associations between sleeping pills consumption and sociodemographic factors (age, gender, race/skin colour, geographic region and income), health status/behaviour characteristics (poor self-rated health status, number of chronic conditions and alcohol consumption) and variables related to healthcare utilisation (number of visits, usual source of care, care coordination, doctor’s awareness of all medication, difficulty in managing own medication and number of medicines).ConclusionsOur work found that sleeping pills consumption is disproportionately prevalent among women, is associated with worse health status and increases with more medical office visits and use of additional medicines. Moreover, the large inexplicable variations in care deserve special attention from policy-makers and clinicians.

The continent of the Americas has the greatest number of people infected and deaths associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the world. Brazil occupies the 2nd position in numbers of infected cases and deaths, preceded only by the United States. Older adults and those with pre-existing chronic illnesses are more vulnerable to the consequences of the virus. The SARS-CoV-2 epidemic has serious consequences for health services. Therefore, an assessment of the pandemic’s effect on the older Brazilian population is urgently needed. The study examines the prevalence of COVID-19 related symptoms, care-seeking, and cancellation of surgery or other scheduled medical care among a nationally representative sample of Brazilians aged 50 and over derived from the Brazilian Longitudinal Study of Aging (ELSI-Brazil) and a telephone follow-up survey (the ELSI-COVID-19 initiative) between late May and early June 2020. About 10.4% of older adults reported any fever, dry cough or difficulty breathing in the 30 days prior to the interview, with the highest prevalence in the North region (50%). Among individuals with symptoms, only 33.6% sought care. Individuals living in the South or Southeast regions were significantly less likely to seek care for COVID-19 related symptoms. Nearly one in six participants had to cancel scheduled surgery or other medical care; this proportion was higher among women, those with more education, and people with multiple chronic conditions. This paper is among the first to investigate the effect of COVID-19 on health care use in Brazil among older adults. Results highlight the need to adapt health care delivery (such as through telemedicine) to ensure the continuity of care as well as the urgent need for wide dissemination of information to guide the population on disease prevention measures and how to obtain healthcare when needed.

ObjectivesVaccine hesitancy may represent a barrier to effective COVID-19 immunisation campaigns. This study assesses individual, disease-specific and contextual factors associated with COVID-19 vaccine acceptance among a nationally representative sample of older Brazilian adults.DesignCross-sectional analysis of data from household interviews and a supplementary telephone survey.SettingBrazil and its five geographic regions.ParticipantsData are derived from 6584 individuals aged 50 years and over who participated in the second wave of the Brazilian Longitudinal Study of Aging.Primary and secondary outcome measuresSurvey-weighted multinomial logistic regression assesses factors associated with intending, not intending or being uncertain about one’s intention to vaccinate against COVID-19.FindingsSeventy-one per cent of study participants intend to receive a COVID-19 vaccine once available, while 17% (representative of nearly 9 million people) have no intention to vaccinate, and 12% are still undecided. Besides age, demographic and health-related factors related to COVID-19 severity and complications were not associated with intention to vaccinate. Those who most trusted social media or friends and family for COVID-19 information and those who did not trust any information source were 68% and 78% more likely to refuse vaccination, respectively, as compared with those who trusted official information sources. People who inconsistently used face masks when outside were 3.4 times more likely than consistent face mask users to intend to refuse vaccination. Higher municipal COVID-19 fatality rates were negatively associated with vaccine refusal.ConclusionsMost national COVID-19 immunisation strategies identify older individuals as among those prioritised for early vaccination, given their increased risk of more severe symptoms and complications of the disease. Because individual, disease-specific, and contextual factors were associated with vaccine acceptance, there is a clear need for multilevel and multichannel information and outreach campaigns to increase COVID-19 vaccine acceptance among vulnerable older populations.

Importance Missed opportunities for human papillomavirus (HPV) vaccination during pediatric health care visits are common. Objectives To evaluate the effect of online communication training for clinicians on missed opportunities for HPV vaccination rates overall and at well-child care (WCC) visits and visits for acute or chronic illness (hereafter referred to as acute or chronic visits) and on adolescent HPV vaccination rates. Design, Setting, and Participants From December 26, 2018, to July 30, 2019, a longitudinal cluster randomized clinical trial allocated practices to communication training vs standard of care in staggered 6-month periods. A total of 48 primary care pediatric practices in 19 states were recruited from the American Academy of Pediatrics Pediatric Research in Office Settings network. Participants were clinicians in intervention practices. Outcomes were evaluated for all 11- to 17-year-old adolescents attending 24 intervention practices (188 clinicians) and 24 control practices (177 clinicians). Analyses were as randomized and performed on an intent-to-treat basis, accounting for clustering by practice. Interventions Three sequential online educational modules were developed to help participating clinicians communicate with parents about the HPV vaccine. Weekly text messages were sent to participating clinicians to reinforce learning. Statisticians were blinded to group assignment. Main Outcomes and Measures Main outcomes were missed opportunities for HPV vaccination overall and for HPV vaccine initiation and subsequent doses at WCC and acute or chronic visits (visit-level outcome). Secondary outcomes were HPV vaccination rates (person-level outcome). Outcomes were compared during the intervention vs baseline. Results Altogether, 122 of 188 clinicians in intervention practices participated; of these, 120, 119, and 116 clinicians completed training modules 1, 2, and 3, respectively. During the intervention period, 29 206 adolescents (14 664 girls [50.2%]; mean [SD] age, 14.2 [2.0] years) made 15 888 WCC and 28 123 acute or chronic visits to intervention practices; 33 914 adolescents (17 069 girls [50.3%]; mean [SD] age, 14.2 [2.0] years) made 17 910 WCC and 35 281 acute or chronic visits to control practices. Intervention practices reduced missed opportunities overall by 2.4 percentage points (−2.4%; 95% CI, −3.5% to −1.2%) more than controls. Intervention practices reduced missed opportunities for vaccine initiation during WCC visits by 6.8 percentage points (−6.8%; 95% CI, −9.7% to −3.9%) more than controls. The intervention had no effect on missed opportunities for subsequent doses of the HPV vaccine or at acute or chronic visits. Adolescents in intervention practices had a 3.4-percentage point (95% CI, 0.6%-6.2%) greater improvement in HPV vaccine initiation compared with adolescents in control practices. Conclusions and Relevance This scalable, online communication training increased HPV vaccination, particularly HPV vaccine initiation at WCC visits. Results support dissemination of this intervention. Trial Registration ClinicalTrials.gov Identifier:NCT03599557

Objective To assess the association between availability of paid sick leave among parents and children's use of several distinct types of nonurgent health services and emergency care. Methods Using pooled 2013 to 2017 data from the National Health Interview Survey (NHIS), we created dyadic units of observation linking adults with their children (n = 21 235). Descriptive statistics, logistic regressions for binary outcomes, and regular and zero-inflated negative binomial regressions for count outcomes assessed the relationship between parental coverage by paid sick leave benefits and 12 dependent variables related to health care utilization. Regression analyses controlled for a set of child, parent, and family covariates. Results Overall, 58.3% of individuals in our sample reported having paid sick leave in their current or latest job. There are substantial disparities in availability of paid sick leave in terms of parent sex, race, education, and income. Controlling for covariates, the odds of children with at least one parent with access to paid sick leave having any visit to a medical office in the past 12 months are 27% higher than for children whose parents do not have this benefit. Similar positive associations were observed for general doctor visit (OR = 1.18, 95%CI: 1.05-1.32), mental health professional visit (OR = 1.19, 95%CI: 1.01-1.42), and receipt of flu vaccination (OR = 1.21, 95%CI: 1.11-1.33). There was no statistically significant association with emergency room use, once covariates were controlled. Conclusions Availability of paid sick leave among parents is associated with increased children's utilization of nonemergency health services and primary care.

Background: Active management of existing health technologies (e.g., devices, diagnostic, and/or medical procedures) to ensure the delivery of high value care is increasingly recognized around the world. A number of initiatives have raised awareness of technologies that may be overused, mis-used, or potentially harmful by compiling them into lists of low value care. However, despite the growing number of lists, changes to local healthcare practices remain challenging for many systems. The objective of this study was to develop and implement a process, leveraging existing initiatives and data assets, to produce a list of prioritized low value technologies for health technology reassessment (HTR). Methods: An expert advisory committee comprised of clinical experts and health system decision-makers was convened to determine key process requirements. Once developed, the process was piloted to assess feasibility in the Canadian province of British Columbia (BC). Results: The expert advisory committee identified five required attributes for the process: data-driven, routine and replicable, actionable, stakeholder collaboration, and high return on investment. Guided by these attributes, a 5-step process was developed. First, over 1300 published low value technologies (i.e., from the National Institute for Health and Care Excellence [NICE] “do not do” recommendations, low value technologies in the Australian Medical Benefits Schedule, and Choosing Wisely “Top 5” lists) were identified. Using appropriate coding systems for BC’s administrative health data (e.g., International Classification of Diseases [ICD]), the low value technologies were queried to examine frequencies and costs of technology use. This information was used to rank potential candidates for reassessment based on high annual budgetary impact. Lastly, clinical experts reviewed the ranked technologies prior to broad dissemination and stakeholder action. Pilot testing of the process in BC resulted in the prioritization of 9 initial candidate technologies for reassessment. Conclusions: This is the first account of a systematic approach to move a collective body of low value technology recommendations into action in a healthcare setting. This work demonstrates the feasibility and strength of using administrative data to identify and prioritize low value technologies for HTR at a population-level.

Rules and principles for guiding decision-making in the health care sector have been debated for decades. Here, we present a critical appraisal of the two most important paradigms in this respect: welfarism and extra-welfarism. While the former deals with the maximization of the overall sum of individual utilities as its primary outcome, the latter has been focusing on the maximization of the overall health status. We argue that welfarism has three main problems: (1) its central idea of overall sum of individual utilities does not capture societal values decisively relevant in the context of health; (2) the use of the Potential Pareto Improvement brings an unresolvable separation between efficiency and equity; and (3) individual utility may not be a good measure in the health sector, given that individuals might value things that diminish their overall health. In turn, the extra-welfarist approach is criticized regarding four main limitations: (1) the advocated expansion of the evaluative space, moving from utility to health, may have represented in reality a narrowing of it; (2) it operates using non-explicit considerations of equity; (3) it still holds the issue of “inability to desire” of unprivileged people being considered the best judges of weighing the criteria used to building the health measures; and (4) there is controversial empirical evidence about society members’ values that support its assumptions. Overall, both paradigms show significant weaknesses, but the debate has still been within the realm of welfare economics, and even the new approaches to resource allocation in health care systems appear to be unable to escape from these boundaries. Resumo: Há décadas se discutem as regras e os princípios para a tomada de decisões no setor de saúde. O artigo apresenta uma avaliação crítica dos dois paradigmas mais importantes nessa área: welfarism e extra-welfarism. O primeiro lida com a maximização da soma total das utilidades individuais como desfecho primário, enquanto o segundo concentra-se na maximização do estado geral de saúde. Argumentamos que o welfarism apresenta três problemas principais: (1) a ideia central da soma total das utilidades individuais não capta os valores da sociedade que são decisivos no contexto da saúde; (2) o uso da Potencial Melhoria de Pareto introduz uma separação irresolvível entre eficiência e equidade e (3) a utilidade individual pode não ser uma medida adequada no setor da saúde, uma vez que os indivíduos podem valorizar coisas que diminuem seu estado geral de saúde. Enquanto isso, os críticos apontam quatro limitações principais na abordagem extra-welfarist: (1) a proposta de expansão do espaço avaliativo, passando da utilidade para a saúde, na realidade pode redundar no estreitamento desse mesmo espaço; (2) a abordagem opera com considerações não explícitas de equidade; (3) ainda mantém a questão da “incapacidade de desejar” das pessoas de baixa renda que são consideradas os melhores avaliadores dos critérios utilizados para construir as medidas de saúde e (4) há controvérsias em torno das evidências empíricas sobre os valores dos membros da sociedade que sustentam as premissas. No geral, ambos os paradigmas demonstram fraquezas significativas, mas o debate continua dentro do campo da economia do bem-estar social, e mesmo as novas abordagens à alocação de recursos nos sistemas de saúde parecem ser incapazes de fugir desses limites. Resumen: Las normas y los principios para guiar la toma de decisiones en el sector de la salud se han debatido durante décadas. Presentamos una valoración crítica de los dos paradigmas más importantes a este respecto: el welfarism y el extra-welfarism. Mientras que el primero se ocupa de la maximización de la suma global de las utilidades individuales como su resultado primario, este último se ha centrado en la maximización del estado general de salud. Argumentamos que el welfarism tiene tres problemas principales: (1) su idea central de la suma global de las utilidades individuales no captura los valores societales decisivamente relevantes en el contexto de la salud; (2) el uso de la Mejora Potencial de Pareto trae una separación insoluble entre la eficiencia y la equidad; y (3) la utilidad individual puede no ser una buena medida en el sector de la salud, dado que las personas pueden valorar cosas que disminuyen su salud general. A su vez, el enfoque extra-welfarista es criticado con respecto a cuatro limitaciones principales: (1) la expansión del espacio evaluativo propugnada, pasando de la utilidad a la salud, puede haber representado en la realidad un estrechamiento de la misma; (2) opera con consideraciones no explícitas de equidad; (3) todavía sostiene la cuestión de la “inhabilidad de deseo” de las personas no privilegiadas que se consideran los mejores jueces de pesar los criterios usados para construir las medidas de la salud; y (4) hay evidencia empírica polémica sobre los valores de los miembros de la sociedad que apoyan sus suposiciones. En general, ambos paradigmas muestran debilidades significativas, pero el debate aún se encuentra dentro del ámbito de la economía del bienestar, e incluso los nuevos enfoques para la asignación de recursos en los sistemas de atención de salud parecen ser incapaces de escapar de estos límites.

A method based on liquid-liquid extraction followed by high-performance liquid chromatography (HPLC) with positive ion electrospray ionization tandem mass spectrometry (ESI-MS/MS) detection was developed for the simultaneous determination of lopinavir (LPV) and ritonavir (RTV) in human blood, semen and saliva samples. The acquisition was performed in multiple reaction monitoring (MRM) mode, monitoring the transitions: m/z 629 > 447.1 for LPV, 721.18 > 268.02 for RTV and m/z 747.22 > 322.03 for the internal standard (IS). The limit of quantification was 1 ng/mL for both analytes in all matrices. The method was linear in the studied range (1-2000 ng/mL for LPV and 1-200 ng/mL for RTV), with r2 > 0.99 for each drug, and the run time was 4.5 min. The intra-assay precisions (%) were in the ranges of 0.1-14.2 (LPV) and 0.4-12.7 (RTV), the inter-assay precisions were in the ranges of 2.8-15.3 (LPV) and 1.1-12.8 (RTV) and the intra-and inter-assay recoveries were >85% for both drugs. The extraction efficiencies were 73.5-118.4% for LPV and 74.4-126.2% for RTV. The analytical method was applied to measure LPV and RTV concentrations in blood plasma (total and unbound fraction), saliva and semen of six HIV+ individuals under stable treatment with Kaletra soft gel capsules. The results were consistent with previously published data.