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Despite efforts to improve detection and treatment of adults with hypertension and diabetes in Argentina, many public healthcare system users remain undiagnosed or face barriers in managing these diseases. The purpose of this study is to identify health system, provider, and user-related factors that may hinder detection and treatment of hypertension and diabetes using a traditional and behavioral economics approach. We did qualitative research using in-depth semistructured interviews and focus groups with healthcare providers and adult users of Public Primary Care Clinics. Health system barriers included inadequate care accessibility; poor integration between primary care clinics and local hospitals; lack of resources; and gender bias and neglect of adult chronic disease. Healthcare provider–related barriers were inadequate training; lack of availability or reluctance to adopt Clinical Practice Guidelines; and lack of counseling prioritization. From a behavioral economics perspective, bottlenecks were related to inertia and a status quo, overconfidence, and optimism biases. User-related barriers for treatment adherence included lack of accurate information; resistance to adopt lifelong treatment; affordability; and medical advice mistrust. From a behavioral economics perspective, the most significant bottlenecks were overconfidence and optimism, limited attention, and present biases. Based on these findings, new interventions that aim to improve prevention and control of chronic conditions can be proposed. The study provides empirical evidence regarding the barriers and bottlenecks in managing chronic conditions in primary healthcare settings. Results may contribute to the design of behavioral interventions targeted towards healthcare provision for the affected population.

Background: Worldwide, smoking tobacco causes 7 million deaths annually, and this toll is expected to increase, especially in low-income and middle-income countries. In Latin America, smoking is a leading risk factor for death and disability, contributes to poverty, and imposes an economic burden on health systems. Despite being one of the most effective measures to reduce smoking, tobacco taxation is underused and cigarettes are more affordable in Latin America than in other regions. Our aim was to estimate the tobacco-attributable burden on mortality, disease incidence, quality of life lost, and medical costs in 12 Latin American countries, and the expected health and economic effects of increasing tobacco taxes. Methods: In this modelling study, we developed a Markov probabilistic microsimulation economic model of the natural history, medical costs, and quality-of-life losses associated with the most common tobacco-related diseases in 12 countries in Latin America. Data inputs were obtained through a literature review, vital statistics, and hospital databases from each country: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, Honduras, Mexico, Paraguay, Peru, and Uruguay. The main outcomes of the model are life-years, quality-adjusted life-years, disease events, hospitalisations, disease incidence, disease cost, and healthy years of life lost. We estimated direct medical costs for each tobacco-related disease included in the model using a common costing methodology for each country. The disease burden was estimated as the difference in disease events, deaths, and associated costs between the results predicted by the model for current smoking prevalence and a hypothetical cohort of people in each country who had never smoked. The model estimates the health and financial effects of a price increase of cigarettes through taxes, in terms of disease and health-care costs averted, and increased tax revenues. Findings: In the 12 Latin American countries analysed, we estimated that smoking is responsible for approximately 345 000 (12%) of the total 2 860 921 adult deaths, 2·21 million disease events, 8·77 million healthy years of life lost, and $26·9 billion in direct medical costs annually. Health-care costs attributable to smoking were estimated to represent 6·9% of the health budgets of these countries, equivalent to 0·6% of their gross domestic product. Tax revenues from cigarette sales cover 36·0% of the estimated health expenditures caused by smoking. We estimated that a 50% increase in cigarette price through taxation would avert more than 300 000 deaths, 1·3 million disease events, gain 9 million healthy life-years, and save $26·7 billion in health-care costs in the next 10 years, with a total economic benefit of $43·7 billion. Interpretation: Smoking represents a substantial health and economic burden in these 12 countries of Latin America. Tobacco tax increases could successfully avert deaths and disability, reduce health-care spending, and increase tax revenues, resulting in large net economic benefits. Fil: Pichón-riviere, Andres. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Alcaraz, Andrea. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Palacios, Alfredo. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Rodríguez, Belén. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Reynales Shigematsu, Luz Myriam. Instituto Nacional de Salud Pública; México Fil: Pinto, Márcia. Fundación Oswaldo Cruz; Brasil Fil: Castillo Riquelme, Marianela. Ministerio de Salud; Chile Fil: Peña Torres, Esperanza. Instituto de Evaluación Tecnológica En Salud; Colombia Fil: Osorio, Diana Isabel. Instituto de Evaluación Tecnológica en Salud; Colombia Fil: Huayanay, Leandro. Universidad Peruana Cayetano Heredia; Perú Fil: Loza Munarriz, Cesar. Universidad Peruana Cayetano Heredia; Perú Fil: Sáenz de Miera-Juárez, Belén. Universidad Autónoma de Baja California Sur; México Fil: Gallegos Rivero, Verónica. Centro Nacional de Excelencia Tecnológica en Salud; México Fil: De La Puente, Catherine. Universidad de La Frontera; Chile Fil: Navia Bueno, María del Pilar. Universidad Mayor de San Andrés; Bolivia Fil: Caporale, Joaquín. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Roberti, Javier Eugenio. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Virgilio, Sacha Alexis. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Augustovski, Federico Ariel. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Bardach, Ariel Esteban. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina

Objetivos. Estimar la carga de enfermedad asociada al consumo de tabaco en Paraguay y evaluar el potencial efecto económico y sanitario del aumento de precio mediante impuestos. Materiales y métodos. Se diseñó un modelo de microsimulación de Monte Carlo que incorporó la historia natural, costos y calidad de vida de enfermedades asociadas al tabaquismo para el 2015. Asimismo, se estimó el impacto en varios escenarios de aumento de impuestos sobre la prevalencia de tabaquismo y la recaudación fiscal. Resultados. 3354 personas mueren al año en Paraguay por consecuencia del tabaquismo. El 19 % de las muertes son por enfermedad isquémica cardíaca, el 15 % por accidentes cerebrovasculares. El 77 % de las muertes por enfermedad pulmonar obstructiva crónica y el 83 % de cáncer de pulmón son atribuibles al tabaquismo. Estas enfermedades en Paraguay representan un costo médico directo anual de más de 1,5 x 106 millones de guaraníes, mientras la recaudación impositiva por la venta de cigarrillos apenas llega a cubrir un 20 % de este gasto. Un aumento en el precio de los cigarrillos del 50 % vía impuestos, podría llevar a evitar 2507 muertes en diez años y generar recursos por 2,4 x 106 millones por ahorro en gastos sanitarios y aumento de recaudación. Conclusiones. El costo y la carga de enfermedad asociado al consumo de tabaco en el sistema de salud es elevado en Paraguay. Un aumento del precio de los cigarrillos a través de los impuestos tendría importantes beneficios sanitarios y podría compensar parcialmente los costos sanitarios. Objectives. To consider the burden of disease associated to tobacco consumption in Paraguay and to evaluate the potential economic and health effect of price increase through taxes. Materials and Methods. A Monte Carlo simulation model was designed incorporating natural history, costs, and quality of life of diseases associated to smoking for 2015. Also, several scenarios were considered for the impact of tax raises on the prevalence of smoking and fiscal collection. Results. In Paraguay, 3,354 people die every year as a consequence of smoking. Nineteen percent of deaths are due to cardiac ischemia, 15% due to stroke. 77% of deaths due to chronic obstructive pulmonary disease (COPD), and 83% of lung cancer can be attributed to smoking. These diseases in Paraguay represent an annual direct medical cost of more than 1.5 trillion PYG, while the tax collection from cigarette sales barely covers 20% of this expense. A 50% increase in the price of cigarettes via taxes could avoid 2507 deaths in ten years and generate resources by 2.4 trillion in savings in health expenses and tax of collection. Conclusions. The cost and the burden of disease associated to tobacco consumption is high in the health system in Paraguay. An increase in cigarette price through taxes could have significant health benefits and could offset health costs in part. Fil: Bardach, Ariel Esteban. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Cañete, Felicia. Ministerio de Salud Pública y Bienestar Social; Paraguay Fil: Sequera, Víctor Guillermo. Ministerio de Salud Pública y Bienestar Social; Paraguay Fil: Palacios, Alfredo. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Alcaraz, Andrea. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Rodríguez, Belén. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Caporale, Joaquín. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Augustovski, Federico Ariel. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Pichón-Riviere, Andrés. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina

Background The measurement of health benefits is a key issue in health economic evaluations. There is very scarce empirical literature exploring the differences of using quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs) as benefit metrics and their potential impact in decision-making. Methods Two previously published models delivering outputs in QALYs, were adapted to estimate DALYs: a Markov model for human papilloma virus (HPV) vaccination, and a pneumococcal vaccination deterministic model (PNEUMO). Argentina, Chile, and the United Kingdom studies were used, where local EQ-5D social value weights were available to provide local QALY weights. A primary study with descriptive vignettes was done (n = 73) to obtain EQ-5D data for all health states included in both models. Several scenario analyses were carried-out to evaluate the relative importance of using different metrics (DALYS or QALYs) to estimate health benefits on these economic evaluations. Results QALY gains were larger than DALYs avoided in all countries for HPV, leading to more favorable decisions using the former. With discounting and age-weighting – scenario with greatest differences in all countries – incremental DALYs avoided represented the 75%, 68%, and 43% of the QALYs gained in Argentina, Chile, and United Kingdom respectively. Differences using QALYs or DALYs were less consistent and sometimes in the opposite direction for PNEUMO. These differences, similar to other widely used assumptions, could directly influence decision-making using usual gross domestic products (GDPs) per capita per DALY or QALY thresholds. Conclusion We did not find evidence that contradicts current practice of many researchers and decision-makers of using QALYs or DALYs interchangeably. Differences attributed to the choice of metric could influence final decisions, but similarly to other frequently used assumptions. Fil: Augustovski, Federico Ariel. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Pque. Centenario. Centro de Investigaciones En Epidemiología y Salud Publica. Instituto de Efectividad Clinica y Sanitaria. Centro de Investigaciones En Epidemiología y Salud Publica.; Argentina Fil: Colantonio, Lisandro Damián. University of Alabama at Birmingahm; Estados Unidos Fil: Galante, Julieta. Cardiff University; Reino Unido Fil: Bardach, Ariel Esteban. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Pque. Centenario. Centro de Investigaciones En Epidemiología y Salud Publica. Instituto de Efectividad Clinica y Sanitaria. Centro de Investigaciones En Epidemiología y Salud Publica.; Argentina Fil: Caporale, Joaquín E.. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Pque. Centenario. Centro de Investigaciones En Epidemiología y Salud Publica. Instituto de Efectividad Clinica y Sanitaria. Centro de Investigaciones En Epidemiología y Salud Publica.; Argentina Fil: Zárate, Víctor. Universidad San Sebastian; Chile Fil: Chuang, Ling Hsiang. Pharmerit; Países Bajos Fil: Pichón-Riviere, Andrés. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Pque. Centenario. Centro de Investigaciones En Epidemiología y Salud Publica. Instituto de Efectividad Clinica y Sanitaria. Centro de Investigaciones En Epidemiología y Salud Publica.; Argentina Fil: Kind, Paul. University of Leeds; Reino Unido

Objetivo: estimar la carga de enfermedad asociada al consumo de tabaco en Colombia y evaluar el potencial efecto sanitario y económico del aumento de precio en los cigarrillos mediante impuestos.Materiales y métodos: se diseñó un modelo de simulación de Monte Carlo de primer orden que incorporó la historia natural, los costos y la calidad de vida de enfermedades relacionadas con el consumo de tabaco en adultos. Se estimó el impacto en la prevalencia de tabaquismo y en la recaudación de diferentes escenarios de aumento de precio a través de impuestos.Resultados: en Colombia cada año mueren 32.088 personas como consecuencia del consumo de cigarrillo y pueden atribuírsele los siguientes porcentajes: el 16% de las muertes cardiovasculares, el 13% de las producidas por accidentes cerebrovasculares, el 77% de las muertes ocasionadas por enfermedad pulmonar obtructiva crónica y el 80% de las muertes por cáncer de pulmón. Las enfermedades relacionadas con el cigarrillo representan un costo directo anual al sistema de salud de más de 4,5 billones de pesos, mientras la recaudación impositiva por la venta de cigarrillos apenas logra cubrir un 10% de este gasto. Un aumento en el precio de los cigarrillos del 50% podría evitar, en un horizonte de 10 años, más de 45.000 muertes y generar recursos por 8 billones por ahorro en gastos sanitarios y aumento de recaudación.Conclusiones: la carga de enfermedad y el costo para el sistema de salud asociados al consumo de tabaco son muy elevados en Colombia. Un aumento del precio de los cigarrillos a través de los impuestos tendría importantes bene cios tanto sanitarios como económicos. Objective: to estimate the burden of disease associated with tobacco consumption in Colombia and to evaluate the potential health and economic effect of the price increase in cigarettes through taxes. Materials and methods: to estimate the burden of disease, a first-order Monte Carlo simulation model was designed that incorporated the natural history, costs and quality of life of diseases related to tobacco consumption in adults. A tax model was designed to calculate the impact on the prevalence of smoking and on the collection of different price increase scenarios. Results: according to the proposed model, it can be estimated that in Colombia 26,464 people die every year as a result of cigarette smoking. 13% of cardiovascular deaths, 13% of those caused by strokes, 77% of deaths caused by chronic lung disease and 81% of deaths from lung cancer can be attributed to their consumption. The diseases related to cigarettes in Colombia represent a direct annual cost of more than 4 billion pesos, while the tax collection from the sale of cigarettes barely covers 10% of this expense. An increase in the price of cigarettes of 50% could prevent more than 30,000 deaths in ten years and generate resources for 7.9 billion savings in health spending and increased collection. Conclusions: the burden of disease and the cost to the health system associated with tobacco use are very high in Colombia. An increase in the price of cigarettes through taxes would have important health and economic benefits for Colombia. Fil: Peña Torres, Esperanza. Instituto Nacional de Cancerología; Colombia Fil: Osorio, Diana. Instituto de Evaluación Tecnológica En Salud ; Colombia Fil: Gamboa, Oscar. Instituto Nacional de Cancerología; Colombia Fil: Caporale, Joaquín. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Augustovski, Federico Ariel. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Alcaraz, Andrea. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Bardach, Ariel Esteban. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Mejía, Aurelio. Instituto de Evaluación Tecnológica En Salud ; Colombia Fil: Pichón-riviere, Andres. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina

Objective To estimate and compare type 2 diabetes mellitus treatment costs in insulin-naive patients following initiation of therapy with either insulin glargine (IG) or insulin detemir (ID) over 1-year time horizon from a payers' perspective in Argentina. Methods We used a pharmacoeconomic model based on a randomized trial comparing IG and ID (Rosenstock J, Davies M, Home PD, et al. A randomised, 52-week, treat-to-target trial comparing insulin detemir with insulin glargine when administered as add-on to glucose-lowering drugs in insulin-naive people with type 2 diabetes. Diabetologia 2008;51:408–16) and Argentinean sources. Clinical, resource use, and cost data were combined to estimate direct medical costs (insulin, test strips, and needles) during the first year. Price per international unit of insulin is similar for IG and ID in the local market. Deterministic analysis was performed on insulin unit cost and probabilistic sensitivity analyses on clinical, resource use, and unit costs to evaluate contribution to variance on the difference in total annual treatment cost. Results Annual mean treatment cost (Argentinean pesos 2013) was AR $6229 for IG and AR $9257 for ID, showing 33% total cost reduction with IG (AR $3028; exchange rate US $1.00 = AR $5.30). Probabilistic sensitivity analysis showed that IG was cost saving in 88% of the simulations. The most influential parameter was the difference in insulin dose requirements. Threshold analysis showed that if the unit price of ID is reduced by 43%, ceteris paribus, the total annual costs per person for both insulin regimens would be the same. Conclusions From a payer's perspective in Argentina, cost savings related to the use of IG represented one third of total treatment costs. Sensitivity analyses confirmed the robustness of these results.

To explore the motivations and expectations of the users of the Program for Healthy Centers in the Autonomous City of Buenos Aires and to evaluate its potential health impact.In-depth interviews were conducted (n = 34) and a self-administered survey was sent to users of the program (n = 605). An epidemiological model was developed to estimate the impact of the program on cardiovascular events (CVE) and disability-adjusted life years (DALYs).The main motivating factors for using the healthy centers were geographic and economic accessibility (free services) and satisfaction with the care received. 14.4% (95% CI, 10.3-18.5%) of hypertensive users and 24.8% (95% CI, 17.6-32.0%) of diabetic users reported having learned of their altered values in the healthy center. More than half of the respondents reported some improvement in their knowledge about the benefits of physical activity and healthy eating; this was more frequent among those who were younger, of lower educational level, users of the public health system, users of a healthy center in the South zone and those who had a cardiometabolic risk factor (p0.05). It was estimated that the healthy centers would prevent 12.5 cardiovascular and cerebrovascular events per year in the assisted population (4.75 events/100 000) and 47.75 DALYs due to these causes.The healthy centers are a favorable space for the implementation of health promotion and prevention actions, contributing to the detection of and facilitating the monitoring of risk factors, with a potential to prevent cardiovascular events and its consequences.Explorar as motivações e expectativas dos usuários do Programa Estações Saudáveis na Cidade Autônoma de Buenos Aires e avaliar seu impacto potencial na saúde.Foram realizadas entrevistas em profundidade (n = 34) e uma pesquisa auto-administrada (n = 605) a usuários do programa. Um modelo epidemiológico foi desenvolvido para estimar o impacto do programa em eventos cardiovasculares e anos de vida ajustados por incapacidade (DALY).Os principais fatores motivadores para o uso do estações saudáveis foram a acessibilidade geográfica, econômica (serviços gratuitos) e a satisfação com o atendimento recebido. 14,4% (intervalo de confiança de 95% [IC95%] 10,3-18,5%) de usuários hipertensos e 24,8% (IC95% 17,6-32,0%) dos diabéticos relataram ter aprendido sobre seus valores alterados na estação saudável. Mais da metade dos entrevistados relataram alguma melhora no conhecimento sobre os benefícios da atividade física e da alimentação saudável, com maior freqüência entre os mais jovens, de menor escolaridade, usuários do sistema público de saúde, usuários de estações saudáveis na zona sul e aqueles que apresentaram algum fator de risco cardiometabólico (p0,05). Estimou-se que, devido à existência de estações saudáveis, 12,5 eventos cardiovasculares e cerebrovasculares por ano seriam evitados na população atendida (4,75 eventos/100 000) e 47,75 DALY por essas causas.As estações saudáveis são um espaço propício para a implementação de ações de promoção e prevenção da saúde, contribuindo para a detecção e facilitação do monitoramento dos fatores de risco, com potencial para prevenir os eventos cardiovasculares e suas consequências.

Risk stratification based on results provided by a 21-gene assay (Oncotype DX(®)) in early stage breast cancer can help optimize hormone therapy (HT) and/or chemotherapy (CT) decisions. We performed a systematic review and meta-analysis of decision impact (DI) and net change in CT use before and after assay results, both in the whole studies' population and by recurrence risk score (RS) strata. A systematic search of studies with prospective data collection reported physician's decision on treatment allocation in early stage node-negative breast cancer was performed. DI reflects the proportion of patients whose management was changed, and net change focuses on CT change. A random-effects model is reported. Fifteen studies (N = 2229) met our inclusion criteria: 50.09, 37.35, and 13.38 % of patients with low, intermediate, and high RS. Treatment decision changed in 29.5 % (95 % CI 26.29-32.86). Net reduction of CT use was 12 % (8-17 %). It was 16 % (12.00-19.00) in the low RS group, 0 % (-3.00 to 3.00) in the intermediate RS group, and increased by 2 % (-1.00 to 3.00) in the high RS group. Use of a 21-gene assay showed a significant impact on treatment decisions. From 100 women tested, 30 could have their treatment optimized, and 12 could avoid CT. Its main effects consist of sparing chemotherapy in low risk patients and slightly increasing it in the high risk category. DI could be higher in selected patient populations with greater uncertainty regarding initial treatment decisions.

To estimate the impact of Argentine policies to reduce trans fatty acids (TFA) on coronary heart disease (CHD), disability-adjusted life years (DALYs) and associated health-care costs.We estimated the baseline intake of TFA before 2004 to be 1.5% of total energy intake. We built a policy model including baseline intake of TFA, the oils and fats used to replace artificial TFAs, the clinical effect of reducing artificial TFAs and the costs and DALYs saved due to averted CHD events. To calculate the percentage of reduction of CHD, we calculated CHD risks on a population-based sample before and after implementation. The effect of the policies was modelled in three ways, based on projected changes: (i) in plasma lipid profiles; (ii) in lipid and inflammatory biomarkers; and (iii) the results of prospective cohort studies. We also estimated the present economic value of DALYs and associated health-care costs of coronary heart disease averted.We estimated that projected changes in lipid profile would avert 301 deaths, 1066 acute CHD events, 5237 DALYs and 17 million United States dollars (US$) in health-care costs annually. Based on the adverse effects of TFA intake reported in prospective cohort studies, 1517 deaths, 5373 acute CHD events, 26 394 DALYs and US$ 87 million would be averted annually.Even under the most conservative scenario, reduction of TFA intake had a substantial effect on public health. These findings will help inform decision-makers in Argentina and other countries on the potential public health and economic impact of this policy.Estimer l'impact des politiques argentines de réduction des acides gras trans (AGT) sur les cardiopathies coronariennes (CC), les années de vie corrigées du facteur incapacité (AVCI) et les coûts des soins de santé associés.Nous sommes partis d'une estimation de l'apport de référence en AGT avant 2004 représentant 1,5% de l'apport énergétique total. Nous avons conçu un modèle pour ces politiques, en intégrant cet apport en AGT de référence, les huiles et graisses utilisées pour remplacer les AGT artificiels, les effets cliniques de la réduction des AGT artificiels, les coûts associés ainsi que les AVCI épargnées du fait des accidents coronariens évités. Pour calculer le pourcentage de réduction des CC, nous avons calculé les risques de CC sur un échantillon en population, avant et après la mise en œuvre de ces politiques. Les effets de ces politiques ont été modélisés de trois manières, en fonction des changements projetés: (i) au niveau des profils lipidiques plasmatiques; (ii) au niveau des biomarqueurs lipidiques et inflammatoires et (iii) en fonction des résultats des études prospectives de cohortes. Nous avons également estimé la valeur économique actuelle des AVCI et du coût des soins de santé associés correspondant aux cardiopathies coronariennes évitées.Selon nos estimations, les changements projetés des profils lipidiques devraient permettre d'éviter 301 décès, 1 066 accidents coronariens aigus, 5 237 AVCI et 17 millions de dollars des États-Unis d'Amérique ($US) de dépenses annuelles en soins de santé. À partir des effets défavorables des apports en AGT indiqués dans les études prospectives de cohortes, ce sont 1 517 décès, 5 373 accidents coronariens aigus, 26 394 AVCI et 87 millions de $US de dépenses qui pourraient être évités chaque année.Même dans le scénario le plus prudent, la réduction de l'apport en AGT a un effet considérable sur la santé publique. Ces résultats permettront d'informer les décideurs en Argentine et dans d'autres pays sur les impacts potentiels de ce type de politiques sur le plan économique et en termes de santé publique.Estimar el impacto de las políticas argentinas para la reducción de los ácidos grasos de tipo trans (AGT) en las cardiopatías coronarias, los años de vida ajustados en función de la discapacidad (AVAD) y los costes de la atención sanitaria asociados.Se estimó que la ingesta base de AGT antes de 2004 era de 1,5% de la ingesta de energía total. Se construyó un modelo de política que incluía la ingesta base de AGT, los aceites y grasas utilizados para reemplazar los AGT artificiales, el efecto clínico de reducir los AGT artificiales y el coste y los AVAD salvados debido a los casos de cardiopatías coronarias evitadas. Para calcular el porcentaje de reducción de cardiopatías coronarias, se calcularon los riesgos de cardiopatías coronarias en un modelo basado en la población antes y después de la implementación. El efecto de las políticas fue modelado de tres formas, en base a cambios estimados: (i) perfiles de plasma de lípidos; (ii) marcados biológicos inflamatorios de lípidos; y (iii) los resultados de estudios de cohortes prospectivos. También se estimó el valor económico actual de los AVAD y los costes de atención sanitaria asociados a las cardiopatías coronarias evitadas.Se estimó que los cambios estimados en el perfil de lípidos evitarían 301 muertes, 1.066 casos graves de cardiopatías coronarias, 5.237 AVAD y 17 millones de dólares estadounidenses (USD) en atención sanitaria cada año. Basándose en los efectos adversos del consumo de AGT de los estudios de cohortes prospectivos, se evitarían 1.517 muertes, 5.373 casos graves de cardiopatías coronarias, 26.394 AVAD y 87 millones de USD cada año.Incluso bajo el escenario más conservador, la reducción del consumo de AGT tuvo un efecto sustancial en la salud pública. Estos resultados ayudarán a informar a los responsables de la toma de decisiones en Argentina y otros países sobre el potencial impacto económico y de salud pública de esta política.تقدير أثر السياسات الأرجنتينية للحد من الأحماض الدهنية المتحولة (TFA) على مرض القلبي الوعائي (CHD)، وسنوات العمر المصححة باحتساب مدد العجز (DALYs)، ونفقات الرعاية الصحية المرتبطة بها.تشير تقديراتنا إلى أن نسبة المدخول الأساسي من الأحماض الدهنية المتحولة قبل عام 2004 كانت تبلغ 1.5% من إجمالي مدخول الطاقة. لذلك، قمنا بوضع نموذج لسياسة تتضمن المدخول الأساسي من الأحماض الدهنية المتحولة والزيوت والدهون المستخدمة لتحل محل تلك الأحماض الدهنية المتحولة، والأثر الإكلينيكي لتقليل الأحماض الدهنية المتحولة والتكاليف وسنوات العمر المصححة باحتساب مدد العجز التي يتم توفيرها بسبب تحاشي وقائع الإصابة بالأمراض القلبية الوعائية. ولكي يتم حساب النسبة المئوية لتقليل الإصابة بالأمراض القلبية الوعائية، فقد احتسبنا مخاطر تلك الأمراض على عينة تستند إلى شريحة سكانية قبل تنفيذ السياسة وبعدها. وتم وضع نماذج لأثر السياسات باتباع ثلاث طرق استناداً إلى التغييرات المتوقعة: (1) في أنماط دهون البلازما، و(2) في الدهون والمحددات الحيوية الالتهابية (Inflammatory biomarkers، و(3) نتائج الدراسات الأترابية الاستباقية (Prospective cohort studies). كما وضعنا تقديرًا للقيمة الاقتصادية الحالية لسنوات العمر المصححة باحتساب مدد العجز وما يرتبط بها من تكاليف للرعاية الصحية لمرض القلب الوعائي الذي تم تحاشي الإصابة به.تشير تقديراتنا إلى أن التغييرات المتوقعة في نمط الدهون سيؤدي إلى تحاشي 301 حالة وفاة، و1066 واقعة إصابة بحالات حادة من الأمراض القلبية الوعائية، وإنقاذ 5237 سنة عمر مصححة باحتساب مدد العجز، و17 مليون دولار أمريكي سنويًا من نفقات الرعاية الصحية. وبناءً على الآثار الجانبية لمدخول الأحماض الدهنية المتحولة التي وردت تقارير بشأنها في الدراسات الأترابية الاستباقية، فسيتم تجنب 1517 حالة وفاة، و5373 واقعة إصابة بحالات حادة من الأمراض القلبية الوعائية، وإنقاذ 26,394 سنة عمر مصححة باحتساب مدد العجز، و87 مليون دولار أمريكي سنويًا.حتى في ظل السيناريوهات الأكثر تحفظًا، فقد كان للحد من مدخول الأحماض الدهنية المتحولة أثر كبير على الصحة العامة. ومن شأن هذه النتائج أن تفيد في تقديم المعلومات الكافية لصناع القرار بالأرجنتين وغيرها من البلدان بشأن الأثر المحتمل على الصحة العامة والآثار الاقتصادية لهذه السياسية.旨在评估阿根廷境内关于减少使用反式脂肪酸 (TFA) 的政策对冠心病 (CHD)、残疾调整生命年 (DALY) 和相关医疗保健成本产生的影响。.我们估计出 2004 年之前对反式脂肪酸 (TFA) 的基准摄入量为总能量摄入的 1.5%。 我们构建了政策模型，包括对反式脂肪酸 (TFA) 的基准摄入量、用于代替人工反式脂肪酸 (TFA) 的油脂、减少使用人工反式脂肪酸 (TFA) 的临床效果，以及因预防冠心病 (CHD) 事件而节约的成本和残疾调整生命年 (DALY)。 为了计算冠心病 (CHD) 减少的百分比，我们在实施前后基于研究人群计算了冠心病 (CHD) 风险。 根据预测的变化，以三种方式模拟政策的影响： (i) 血浆中的血脂；(ii) 脂质和炎性标记物；以及 (iii) 前瞻性群组研究的结果。 我们还估计了残疾调整生命年 (DALY) 在当下的经济价值，以及预防冠心病的相关医疗保健成本。.我们估计，血脂变化预计每年将会避免 301 人死亡、1066 例急性冠心病 (CHD) 事件和 5237 个残疾调整生命年 (DALY)，并可节约 1700 万美元 (US$) 的医疗保健成本。 基于前瞻性群组研究中所报告的摄入反式脂肪酸 (TFA) 后产生的不良影响，每年可防止 1517 人死亡、5373 例急性冠心病 (CHD) 事件和 26 394 个残疾调整生命年 (DALY)，并可节约 8700 万美元 (US$)。.即使是在最为保守的情况中，减少摄入反式脂肪酸 (TFA) 也可对公众健康产生重大影响。 这些调查结果将有助于让阿根廷和其他国家的决策制定者了解潜在的公众健康问题和这项政策的经济影响。.Оценить воздействие применяемых в Аргентине политик по уменьшению количества трансжирных кислот в пище (ТЖК) на развитие ишемической болезни сердца (ИБС), на количество лет жизни, утраченных в результате болезни, и на сопутствующие расходы на здравоохранение.По нашим оценкам, до 2004 года 1,5% общего количества пищевых калорий приходилось на ТЖК, и эту величину мы приняли за базовый уровень. Мы разработали модель политики, включающую базовый уровень потребления ТЖК, жиры и масла, которыми планировалось заменить искусственные ТЖК, клинический эффект от снижения уровня ТЖК, а также уровень экономии и количество спасенных лет жизни в результате предотвращения случаев ИБС. Для расчета процентной доли снижения ИБС были рассчитаны риски возникновения ИБС для популяционной выборки до и после реализации вышеуказанной политики. Эффект от применения политик моделировался тремя путями в зависимости от предполагаемых изменений: (i) по профилям липидов в плазме, (ii) по липидам и биомаркерам воспалительного процесса и (iii) по результатам проспективных когортных исследований. Мы также оценили текущее экономическое значение спасенных лет жизни и уменьшения сопутствующих расходов на лечение в случае предотвращения ишемической болезни сердца.По предварительным оценкам, предполагаемые изменения в профиле липидов позволят предотвратить 301 смерть, 1066 острых случаев ИБС, спасти 5237 лет жизни и сэкономить 17 млн долл. США на ежегодных расходах на здравоохранение. Если исходить из неблагоприятных последствий употребления пищевых ТЖК, о которых сообщалось в проспективных когортных исследованиях, то ежегодно можно будет предотвратить 1517 смертей, 5373 острых случая ИБС, спасти 26 394 года жизни и сэкономить 87 млн долл. США на медицинских расходах.Даже при самом неблагоприятном сценарии уменьшение употребления ТЖК в значительной мере повлияет на здоровье населения. Эти результаты помогут информировать ответственных лиц в Аргентине и других странах о потенциальном воздействии такой политики на здоровье населения и национальную экономику.

El cáncer colorrectal (CCR) es una de las principales causas de mortalidad en adultos. En Argentina es la segunda entre las neoplasias, y se observan diferencias en la mortalidad entre las distintas provincias. El rastreo de CCR es subutilizado en Argentina, donde el sistema de salud se encuentra fragmentado. OBJETIVOS: Analizar la costo-efectividad (CE) de diversas estrategias de rastreo basadas en el test de sangre oculta en materia fecal inmunohistoquímico (SOMFihq) anual desde distintos subsectores provinciales. MÉTODOS: Se construyó un modelo de Markov, que permitió comparar tres estrategias: rastreo en población de 50 a 74 años, rastreo en población de 50 a 64 años y no rastreo. RESULTADOS: Se encontraron diferencias de costos y variabilidad clínica. El rastreo a población de 50-74 años presentó una razón de CE incremental levemente mayor que el rastreo en población de 50-64 años, con valores inferiores al producto bruto geográfico per cápita. Este resultado se mostró robusto en el análisis de sensibilidad. CONCLUSIONES: Los resultados comparados en siete subsectores de salud regionales de Argentina —con diferencias epidemiológicas, organizacionales, de capacidad instalada y de recursos, con su variabilidad de práctica clínica y sus diferentes costos— indican de manera robusta que el rastreo de CCR se mantiene costo-efectivo en diversos escenarios. Analizar la CE de intervenciones sanitarias en Argentina requiere tener en cuenta el contexto local de los diferentes subsectores de salud.

Background Deaths from cardiovascular disease (CVD), including coronary heart disease (CHD) and stroke are expected to increase in Latin America. Moderate and regular alcohol consumption confers cardiovascular protection, while binge drinking increases risk. We estimated the effects of alcohol use on the number of annual CHD and stroke deaths and disability-adjusted life years (DALYs) in Argentina. Methods Alcohol use data were obtained from a nationally representative survey (EnPreCosp 2011), and etiological effect sizes from meta-analyses of epidemiological studies. Cause-specific mortality rates were from the vital registration system. Results There were 291,475 deaths in 2010 including 24,893 deaths from CHD and 15,717 from stroke. 62.7% of men and 38.7% of women reported drinking alcohol in the past year. All heavy drinkers (i.e. women who drank >20g/day and men who drank >40g/day of alcohol) met the definition of binge drinking and therefore did not benefit from cardioprotective effects. Alcohol drinking prevented 1,424 CHD deaths per year but caused 935 deaths from stroke (121 ischemic and 814 hemorrhagic), leading to 448 CVD deaths prevented (58.3% in men). Alcohol use was estimated to save 85,772 DALYs from CHD, but was responsible for 52,171 lost from stroke. Conclusions In Argentina, the cardioprotective effect of regular and moderate alcohol drinking is slightly larger than the harmful impact of binge drinking on CVD. However, considering global deleterious effects of alcohol in public health, policies to reduce binge drinking should be enforced, especially for young people. Studies are still needed to elucidate effects on cardiovascular health.

Avoidable hospitalizations for ambulatory care sensitive conditions (AH-ACSCs) identify health problems that could be avoided by improving primary health care (PHC). On the basis of hospital discharges from Argentine public sector facilities, an expert panel convened to define a list of AH-ACSCs for children and adults. AH-ACSCs represented less than 30% of hospitalizations. Compared with country averages, poorer districts showed large differences in trends for adults but not for children. Despite that AH-ACSCs have demonstrated empirical validity to evaluate health system performance, its implementation to assess PHC in countries like Argentina, with pluralistic and fragmented health care systems, remains a big challenge.

Objetivo: Estimar los costos médicos directos atribuibles al tabaquismo en los sistemas de salud de América Latina.Métodos. Se utilizó un modelo de microsimulación para cuantificar el impacto económico en enfermedad cardiovascular y cerebrovascular, enfermedad pulmonar obstructiva crónica (EPOC), neumonía, cáncer de pulmón y otras nueve neoplasias. Se realizó una búsqueda sistemática de datos epidemiológicos y de costos de los eventos. El modelo se calibró y validó para Argentina, Bolivia, Brasil, Chile, Colombia, México y Perú, países que representan el 78% dela población de América Latina; luego se extrapolaron los resultados a nivel regional.Resultados. Cada año el tabaquismo es responsable de 33 576 millones de dólares en costos directos para el sistema de salud. Esto equivale a 0,7% del producto interno bruto (PIB) de la región y a 8,3% del presupuesto sanitario. La enfermedad cardiovascular, la EPOC y el cáncer fueron responsables de 30,3%, 26,9% y 23,7% de este gasto, respectivamente. El costo atribuible al tabaquismo varió entre 0,4% (México y Perú) y 0,9% (Chile) del PIB y entre 5,2% (Brasil) y 12,7% (Bolivia) del gasto en salud. En la región, la recaudación impositiva por la venta de cigarrillos apenas cubre 37% del gasto sanitario atribuible al tabaquismo (8,1% en Bolivia y 67,3% en Argentina).Conclusiones. El tabaquismo es responsable de una importante proporción del gasto sanitario en América Latina, y la recaudación impositiva por la venta de cigarrillos está lejos de llegara cubrirlo. La profundización de medidas como el aumento de impuestos al tabaco debería ser seriamente considerada por los países de la región. Objective: Estimate smoking-attributable direct medical costs in Latin American health systems. Methods A microsimulation model was used to quantify financial impact of cardiovascular and cerebrovascular disease, chronic obstructive pulmonary disease (COPD), pneumonia, lung cancer, and nine other neoplasms. A systematic search for epidemiological data and event costs was carried out. The model was calibrated and validated for Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, countries that account for 78% of Latin America’s population; the results were then extrapolated to the regional level. Results Every year, smoking is responsible for 33 576 billion dollars in direct costs to health systems. This amounts to 0.7% of the region’s gross domestic product (GDP) and 8.3% of its health budget. Cardiovascular disease, COPD, and cancer were responsible for 30.3%, 26.9%, and 23.7% of these expenditures, respectively. Smoking-attributable costs ranged from 0.4% (Mexico and Peru) to 0.9% (Chile) of GDP and from 5.2% (Brazil) to 12.7% (Bolivia) of health expenditures. In the region, tax revenues from cigarette sales barely cover 37% of smoking-attributable health expenditures (8.1% in Bolivia and 67.3% in Argentina). Conclusions Smoking is responsible for a significant proportion of health spending in Latin America, and tax revenues from cigarette sales are far from covering it. The region’s countries should seriously consider stronger measures, such as an increase in tobacco taxes. Fil: Pichón-Riviere, Andrés. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Bardach, Ariel Esteban. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Augustovski, Federico Ariel. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Alcaraz, Andrea. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Reynales Shigematsu, Luz Myriam. Instituto Nacional de Salud Pública. Centro de Investigación en Salud Poblacional. Departamento de Investigación sobre Tabaco; México Fil: Teixeira Pinto, Márcia. Fundação Oswaldo Cruz. Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente "Fernandes Figueira"; Brasil Fil: Castillo Riquelme, Marianela. Ministerio de Salud. Departamento de Economía de la Salud; Chile Fil: Peña Torres, Esperanza. Instituto de Evaluación Tecnológica en Salud ; Colombia Fil: Isabel Osorio, Diana. Instituto de Evaluación Tecnológica en Salud ; Colombia Fil: Huayanay, Leandro. Universidad Peruana Cayetano Heredia; Perú Fil: Loza Munarriz, César. Universidad Peruana Cayetano Heredia; Perú Fil: Sáenz de Miera-Juárez, Belén. Instituto Nacional de Salud Pública. Centro de Investigación en Salud Poblacional. Departamento de Investigación sobre Tabaco; México Fil: Gallegos Rivero, Verónica. Secretaría de Salud. Centro Nacional de Excelencia Tecnológica en Salud; México Fil: De La Puente, Catherine. Universidad de La Frontera; Chile Fil: Navia Bueno, María del Pilar. Universidad Mayor de San Andrés; Bolivia Fil: Caporale, Joaquín. Instituto de Efectividad Clínica y Sanitaria; Argentina

Objetivo: Evaluar la carga de enfermedad asociada al consumo de tabaco en Argentina y estimarel impacto sanitario y económico de aumentos de precio en los cigarrillos a través de impuestos.Métodos. Se utilizó un modelo de microsimulación para cuantificar el impacto en la mortalidad,calidad de vida y costos atribuibles al tabaquismo por enfermedad cardiovascular, cerebrovasculary pulmonar obstructiva crónica, neumonía y diez neoplasias. Se modeló el efecto dediferentes escenarios de aumento de precio en el consumo de tabaco y su impacto en los ámbitossanitario y económico. Resultados: En Argentina, se pueden atribuir 44 851 muertes, 20 620 diagnósticos decáncer, 14 405 accidentes cerebrovasculares y 68 100 hospitalizaciones por enfermedad cardiovascularpor año al tabaquismo. Cada año se pierden 998 881 años de vida por muerteprematura y discapacidad. El costo de tratar los problemas de salud atribuibles asciende a33 mil millones de pesos argentinos (ARS). Los impuestos al tabaco llegan a cubrir solo67,3% del gasto. Si Argentina aumentara el precio de los cigarrillos en 50%, en los próximos10 años se podrían evitar 25 557 muertes, 42 560 eventos cardiovasculares y 11 222 cánceresy se obtendría un beneficio económico de 122 mil millones de ARS por ahorro de costos sanitariosy aumento de la recaudación impositiva (1 USD = 8,8096 ARS). Conclusiones: La carga de enfermedad y el costo para el sistema de salud atribuibles altabaquismo son muy elevados en Argentina. Un aumento de los impuestos al cigarrillo podríatener importantes beneficios sanitarios y económicos. Objective: Evaluate burden of disease associated with tobacco use in Argentina and estimate health and economic impacts of cigarette price increases through taxes. Methods. A microsimulation model was used to quantify smoking-attributable impact on mortality, quality of life, and costs for cardiovascular, cerebrovascular, and chronic obstructive pulmonary disease; pneumonia; and ten cancers. Modeling was done for effect of different price increase scenarios on tobacco use and their impact on health and economics. Results: In Argentina, 44 851 deaths, 20 620 cancer diagnoses, 14 405 strokes, and 68 100 hospital admissions for cardiovascular disease can be attributed to smoking every year. Every year, 998 881 years of life are lost from premature death and disability. The cost of treating tobacco-attributable health problems amounts to 33 billion Argentine pesos (ARS). Tobacco taxes only cover 67.3% of this expense. If Argentina increases cigarettes prices by 50% in the next 10 years, 25 557 deaths, 42 560 cardiovascular events, and 11 222 cancers could be prevented, with an economic benefit of 122 billion ARS from savings on health costs and from increasing tax revenues (1 US$ = 8.8096 ARS). Conclusions: Smoking-attributable burden of disease and costs to the health system are very high in Argentina. An increase in cigarette taxes could have considerable health and economic benefits. Fil: Alcaraz, Andrea. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Caporale, Joaquín. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Bardach, Ariel Esteban. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Augustovski, Federico Ariel. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Pichón-Riviere, Andrés. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina

Resumen Objectives Heart failure has a great impact on health budget, mainly due to the cost of hospitalizations. Our aim was to describe health resource use and costs of heart failure admissions in three important institutions in Argentina. Methods Multi-center retrospective cohort study, with descriptive and analytical analysis by subgroups of ejection fraction, blood pressure and renal function at admission. Generalized linear models were used to assess the association of independent variables to main outcomes. Results We included 301 subjects; age 75.3±11.8 years; 37% women; 57% with depressed ejection fraction; 46% of coronary etiology. Blood pressure at admission was 129.8±29.7 mmHg; renal function 57.9±26.2 ml/min/1.73 m 2 . Overall mortality was 7%. Average length of stay was 7.82±7.06 days (median 5.69), and was significantly longer in patients with renal impairment (8.9 vs. 8.18; p=0.03) and shorter in those with high initial blood pressure (6.08±4.03; p=0.009). Mean cost per patient was AR$68,861±96,066 (US$=8,071; 1US$=AR$8.532); 71% attributable to hospital stay, 20% to interventional procedures and 6.7% to diagnostic studies. Variables independently associated with higher costs were depressed ejection fraction, presence of valvular disease, and impaired renal function. Conclusions Resource use and costs associated to hospitalizations for heart failure is high, and the highest proportion is attributable to the costs related to hospital stay.

Obtener conocimientos aplicables al diseño de estrategias de prevención, control y tratamiento de la obesidad y otros factores de riesgo cardiovascular (FRCV), para la toma de decisiones basadas en evidencia local y para optimizar el uso de recursos humanos y económicos en entidades de financiamiento de salud. MÉTODOS: estudio observacional y cuantitativo. Se verificaron: a) asociaciones entre obesidad y características demográficas y epidemiológicas; b) eventos fatales, costo por muerte prematura y Años de Vida Saludables Perdidos atribuibles al sobrepeso/obesidad. RESULTADOS: la prevalencia nacional de sobrepeso y obesidad fue de 34,8% y 14,8%, respectivamente, con edades entre 35 y 64 años. Un tercio de la población obesa presentó obesidad severa a muy severa. El 16,2% de los obesos y el 15,1% de las personas con sobrepeso tenían Necesidades Básicas Insatisfechas. El 40,4% de las personas con obesidad presentaron otros FRCV asociados, siendo la hipertensión arterial el más frecuente (48,1%). Las muertes atribuibles al sobrepeso/obesidad fueron 14.776, con lo cual se perdieron 596.704 Años de Vida Saludables atribuibles al exceso de peso y con un costo total por muerte prematura de AR$ 190,5 millones, del cual el 70% fue atribuible al sobrepeso. CONCLUSIONES: es necesario implementar estrategias efectivas de prevención y tratamiento del sobrepeso/ obesidad para disminuir su alto costo económico y los Años de Vida Saludable perdidos por su causa.

ObjectivesTo estimate and compare EuroQol instrument (EQ-5D) health states' values for pneumoccocal and human papillomavirus (HPV) diseases in Argentina, Chile, and the United Kingdom.MethodsTwelve vignettes were designed, pilot-tested, and administered to a convenience sample in a cross-sectional design to elicit descriptive EQ-5D state data. Country-specific EQ-5D time-trade-off-based weights were used to map these descriptive health states into local country preference weights. Descriptive analysis is reported and intercountry differences for each condition were compared using repeated measures analysis of variance.ResultsSeventy-three subjects completed the survey. Pneumococcal disease-related health states mean values ranged from −0.331 (sepsis, Chile) to 0.727 (auditive sequelae, Argentina). HPV-related conditions ranged from 0.152 (cervical cancer, United Kingdom) to 0.848 (cervical intraepithelial neoplasia 1, Argentina). Chile had consistently the lowest mean values in pneumococcal states and in one HPV state, whereas those of the United Kingdom were the lowest in most HPV states. Argentina had the highest mean values in both diseases. Differences in country-specific values for each health state were statistically (P < 0.001) significant except for six health states in which differences between Chilean and United Kingdom weights were nonsignificant.ConclusionsUtility values for most conditions differed statistically relevantly among analyzed countries, even though the same health states′ descriptive set was valued for each. These results reflect the difference in social weights among different countries, which could be attributed to either different population values or valuation study methodologies. They stress the importance of using local preference weights for context-specific decision making.

OBJETIVO: Estimar la carga de la enfermedad, su proporción atribuible a los principales factores de riesgo cardiovascular modificables y los costos médicos directos por hospitalización, asociados con las enfermedades coronarias y los accidentes cerebrovasculares en Argentina. MÉTODOS: Se elaboró un modelo analítico a partir de los datos de mortalidad en Argentina en 2005 y la prevalencia de los principales factores de riesgo cardiovascular (hipertensión arterial, hipercolesterolemia, sobrepeso, obesidad, hiperglucemia, tabaquismo actual y pasado, sedentarismo y consumo inadecuado de frutas y verduras). Se estimaron la carga de la enfermedad -años potenciales de vida perdidos (APVP) y años de vida saludable (AVISA) perdidos- y los costos de hospitalización por las enfermedades cardiovasculares analizadas. RESULTADOS: En 2005 se perdieron en Argentina más de 600 000 AVISA y se contabilizaron casi 400 000 APVP por enfermedades coronarias y accidentes cerebrovasculares; 71,1% de los AVISA perdidos, 73,9% de APVP y 76,0% de los costos asociados son atribuibles a facto-res de riesgo modificables. La hipertensión arterial fue el factor de riesgo de mayor impacto, tanto en hombres como en mujeres: 37,3% del costo total, 37,5% de los APVP y 36,6% de los AVISA perdidos. CONCLUSIONES: La mayor parte de la carga de la enfermedad en Argentina por enfermedades cardiovasculares está relacionada con factores de riesgo modificables -por lo tanto evitables- y podría reducirse mediante intervenciones poblacionales y clínicas basadas en un enfoque de riesgo, que ya han demostrado ser efectivas en función del costo, asequibles y factibles en países como Argentina.OBJETIVE: Estimate the burden of disease, the proportion attributable to the principal modifiable cardiovascular risk factors, and the direct medical cost of hospitalization associated with coronary heart disease and stroke in Argentina. METHODOLOGY: An analitical model was prepared using Argentina's 2005 mortality data and the prevalence of the principal cardiovascular risk factors (hypertension, hypercholesterolemia, overweight, obesity, hyperglycemia, current and past smoking, sedentary lifestyle, and inadequate intake of fruits and vegetables). The burden of disease-years of potential life lost (YPLL) and years of healthy life lost (YHLL)- and hospitalization costs for the cardiovascular diseases analyzed were estimated. RESULTS: In 2005 over 600 000 YHL were lost in Argentina and the number of YPLL due to heart disease and stroke was calculated at 400 000; 71.1% of the YHLL, 73.9% of the YPLL, and 76.0% of the associated costs were attributable to modifiable risk factors. Hypertension was the risk factor with the greatest impact in both men and in women, responsible for 37.3% of the total cost, 37.5% of the YPLL, and 36.6% of the YHLL. CONCLUSIONS: Most of the burden of disease from cardiovascular disease in Argentina is associated with modifiable, and therefore preventable, risk factors and could be reduced through population-based and clinical interventions that employ a risk approach; such interventions have already proven to be cost effective, accessible, and feasible in countries like Argentina.

Objective To implement a controlled clinical trial (PRODIACOR) in a primary care setting designed 1) to improve type 2 diabetes care and 2) to collect cost data in order to be able to measure cost-effectiveness of three system interventions (checkbook of indicated procedures, patient/provider feedback and complete coverage of medications and supplies) and physician and/or patient education to improve psychological, clinical, metabolic and therapeutic indicators. All three Argentinean health subsectors (public health, social security and the private, prepaid system) are participants in the study. Patients of participating physicians were randomly selected and assigned to one of four groups: control, provider education, patient education, and provider/patient education; the system interventions were provided to all four groups. Baseline results Mean BMI was 29.8 kg/m 2 ; most subjects had blood pressure, fasting glucose and total cholesterol above targets recommended by international standards. Only 1% had had microalbuminuria measured, 57% performed glucose self-monitoring, 37% had had an eye examination and 31% a foot examination in the preceding year. Ten percent, 26% and 73% of people with hyperglycemia, hypertension and dyslipidemia, respectively, were not on medications. Most patients treated with either insulin or oral antidiabetic agents were on monotherapy as were those treated for hypertension and dyslipidemia. WHO-5 questionnaire scores indicated that 13% of the subjects needed psychological intervention. Conclusions Baseline data show multiple deficiencies in the process and outcomes of care that could be targeted and improved by PRODIACOR intervention.

Objetivo. Evaluar la costo-efectividad (CE) de la vacuna tetravalente contra el virus de papiloma humano (VPH) en Argentina, desde la perspectiva del sistema de salud. Material y métodos. Se utilizó un modelo dinámico de transmisión para estimar el impacto en la incidencia de cáncer de cuello uterino (Cacu), verrugas y otras lesiones, en los años de vida ajustados por calidad (AVAC) y en costos sanitarios. Resultados. La vacuna podría reducir en 60% el riesgo de muerte por Cacu y en 67% el de padecer verrugas genitales. Comparada con no vacunar, la estrategia de vacunación mostró un beneficio incremental promedio de 0.00234 AVAC por persona a un costo incremental de 2.36 dólares, con una CE de 1007.55 dólares por AVAC ganado. Los resultados demostraron ser robustos en el análisis de sensibilidad. Conclusiones. La inmunización resultaría costo-efectiva, con una CE inferior a un producto interno bruto per cápita (15 009 dólares) por AVAC ganado. Objective. To assess the cost-effectiveness of the quadrivalent vaccine against human papillomavirus (HPV) in Argentina from the health system perspective. Materials and methods. A dynamic transmission model was used to estimate the impact of the vaccine on the incidence of cervical cancer, warts, and other HPV related diseases; in quality adjusted life years (QALYs); and in healthcare costs. Results. Vaccination could reduce the risk of cervical cancer by 60% and by 67% the risk of genital warts. Compared to a non-vaccine scenario, the immunization strategy showed an incremental benefit of 0.00234 QALY per person at an incremental cost of US$2.36, resulting in an incremental cost-effectiveness ratio of US$1007.55 per QALY gained. Sensitivity analysis proved the robustness of these results. Conclusions. Immunization with the quadrivalent vaccine was a cost-effective intervention in Argentina, and it was far below the threshold of one gross domestic product per capita (US$15 009) per QALY gained. Fil: Pichón-Riviere, Andrés. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Alcaraz, Andrea. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Caporale, Joaquín. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Bardach, Ariel Esteban. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Rey Ares, Lucila. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Klein, Karen. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Calderón, María. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Augustovski, Federico Ariel. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Tatti, Silvio Alejandro. Universidad de Buenos Aires. Facultad de Medicina. Hospital de Clínicas General San Martín; Argentina

Objective : To examine the prevalence, characteristics, and costs of hospitalization and re-hospitalization of diabetic and non-diabetic patients in La Plata, Argentina, and to compare the data with those of developed countries. Research design and methods : We studied all in-hospital registries of diabetic patients enrolled in a health maintenance organization of the Province of Buenos Aires (IOMA, November 1996). For each diabetic patient (127 persons), the characteristics of two other hospitalized non-diabetic patients matched by age and gender were simultaneously recorded. Results : Of the 2200 recorded hospitalizations, 5.8% were for diabetic patients, accounting for 10.5% of the hospitalization cost. Cardiovascular diseases were the major cause of hospitalization in both groups. The per capita hospitalization cost of diabetic patients was significantly higher: US$ 1628.5±1754.0 versus US$ 833±842; P =0.00002. Percent re-hospitalizations were five and a half times higher in diabetic patients ( P =0.0001), and significantly associated with history of severe episodes of acute (odds ratio: 3.61; 95% CI: 1.11–11.70; P =0.03) and chronic (odds ratio: 4.26; 95% CI: 1.60–11.29; P =0.004) complications. Conclusions : The combination of higher and longer hospitalization rates and frequent re-hospitalizations resulted in increased costs for our diabetic population. Implementation of care programs based on education (for physicians and patients) could effectively decrease current and future costs of the disease.

In this paper, we provide a short summary of recent trends and key issues regarding the current status of health technology assessment (HTA) in Latin America. Initially, we describe worldwide and region-wide initiatives that foster the institutionalization of HTA for decision making and health policy in our region. Then, we describe some countries in the region that are worth mentioning for their application of HTA at a national level. The target audiences are those researchers and decision makers interested in following HTA in our region.

Objectives: To examine the impact of cardiovascular disease (CVD) events on patient functionality and productivity on the basis of patient use of public or social/private institution health care. Methods: A secondary analysis was conducted of data drawn from records of Argentinian patients, 3 to 15 months posthospitalization after a CVD event, who had originally participated in a multicountry, cross-sectional study assessing the microeconomic impact of a CVD event. Respondents were stratified according to their use of health care institution (public or social/private). Among these groups, pre- and post-CVD event changes in functionality and productivity were compared. Results: Participants' (N = 431) mean age was 56.5 years, and 73.5% were men. Public sector patients reported significantly higher rates of decline in ability to perform moderate activities (P < 0.05), a greater decrease in time spent at work (P < 0.01), a greater limit in the type of work-related activities (P < 0.01), and a higher rate of emotional problems (P < 0.01). Having health insurance (private or social) (odds ratio [OR] = 0.55; 95% confidence interval [CI] 0.35-0.85; P < 0.01) and a higher income (OR = 0.99; 95% CI 0.99-0.99; P < 0.01) were inversely and significantly associated with loss of productivity. Cerebrovascular disease (OR = 2.55; 95% CI 1.42-4.60; P < 0.01) was also significantly associated with productivity loss. Conclusions: In Argentina, patients receiving care in the public sector experienced a greater impact on functionality and productivity after their hospitalization for a CVD event. Lack of insurance, low income, and cerebrovascular disease event were the major determinants of productivity loss. Further investigation is needed to better understand contributors to these differences. Fil: Calcagno, Juan I.. Fogarty International Clinical Research Scholars Program; Estados Unidos. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Iribarren, Sarah J.. Instituto de Efectividad Clínica y Sanitaria; Argentina. Fogarty International Clinical Research Scholars Program; Estados Unidos. Columbia University; Estados Unidos Fil: Caporale, Joaquín E.. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Pearce, Patricia F.. Loyola University; Estados Unidos Fil: Prabhakaran, Dorairaj. Centre For Chronic Disease Control; India Fil: Pichón-Riviere, Andrés. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina

Objectives: Industrial trans fatty acids (TFA) increase CHD risk, but use remains high in developing nations. From 2004-2014, Argentina initiated policies to reduce industrial TFA: voluntary agreements with industry in 2004, mandatory labeling in 2006, and elimination by Food Code by 2014. We aimed to evaluate the policy’s impact on CHD, DALYs and costs. Methods: A review of diet trials, local studies, and consultations with experts was performed to estimate baseline TFA intake in 2004 and types of replacements used by industry from 2004-2014. We built an epidemiological simulation model calculating 3 scenarios to estimate effects of isocaloric replacement of TFA with alternative fats/oils, based on (1) changes in the total:HDL-C ratio (Δ TC/HDL) and (2) changes in other risk biomarkers, and the predicted effects of these biomarker changes on CHD; and (3) observed associations of TFA which CHD events in prospective studies, which may better account for pleiotrophic effects. We used Framingham risk equations to estimate first CHD events with vs. without the policy according to individual age-sex-risk factor distributions (including ΔTC/HDL), utilizing an Argentine population-based sample of 4,000 adults weighted to the full population. Results: After 2014, this policy would prevent each year from 1.3% (based on Δ TC/HDL only; to 7.4% (based on pleiotrophic effects) of all CHD events in Argentina (Table). Accounting for intervention costs and averted events, the policy is actually cost-saving. Conclusions: This is the first model evaluating the impact of an actual policy for eliminating TFA in a developing country. Given the 165,000 annual CHD events in Argentina, at an annual incidence rate of almost 1% in adults, near elimination of industrial TFA might avert under the most conservative assumptions, 1.3% of CHD and saved $36 million. In other low-resource settings, where TFA intake is higher, these effects could be larger. Our findings inform policy makers in Argentina and other developing countries on the huge impact of this policy

Objectives: Cost-effectiveness (CE) is increasingly used for resource allocationworldwide. One key hurdle for its widespread use is the lack of a widely acceptedmethodology to derive thresholds at the healthcare system (HS) or country level.The objective is to propose a methodology and derive local CE thresholds basedon per capita health expenditures (pcHE) and life expectancy (LE). Methods:Our approach is based on the relationship between pcHE and LE; assuming thatthe increase in expenditures reflects the CE of the interventions added to reachcurrent LE. For HS willing to maintain or increase their secular trend of raisingpcHE in order to improve health, the threshold (measured in units of pcHE) willbe: Threshold=(LE+1)*i-LE; where LE is measured in life-years (LY) or QALYs; and?i? is the ratio of increase in pcHE that the HS is willing to accept to increase LEby one unit (eg i=1.09 for a 9% increase). For HS with cost-containment mandates:Threshold=LE-((LE-1)/i), where ?i? represents the past increase in pcHE togain the last unit of LE. We used OLS to predict ?i? for 185 countries, followingboth a cross-sectional (2013) and a longitudinal approach (2003-2013) using WorldBank data. Results: Depending on income strata and LE, countries can expect toincrease pcHE by 7-10% for an additional LY and between 10-13% for an additionalQALY. This represent cost per QALY thresholds ranging from 9-11 pcHE in HighIncometo 5-8 in Low-Income countries, which translates to thresholds of 32-40thousands US dollars in UK; 83-101 in USA; 6-7 in Mexico and 0.5 in Uganda (around0.9, 1.8, 0.6 and 0.7 GDP per capita respectively). Conclusions: This approach,based on widely available data, can be useful to inform decisions in all countriesusing economic evaluations. Our results show thresholds usually lower than thosepromoted by WHO Fil: Pichón-Riviere, Andrés. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Augustovski, Federico Ariel. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Garcia Marti, S. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Caporale, J. Instituto de Efectividad Clínica y Sanitaria; Argentina

BACKGROUND: A recently developed 10-valent pneumococcal non-typeable H influenzae protein D-conjugate vaccine (PHiD-CV) is expected to afford protection against more than two thirds of isolates causing IPD in children in Latin America, and also against acute otitis media caused by both Spn and NTHi. The objective of this study is to assess the cost-effectiveness of PHiD-CV in comparison to non-vaccination in children under 10 years of age in Argentina, Brazil, Chile, Colombia, Mexico and Peru. METHODS: We used a static, deterministic, compartmental simulation model. The dosing regimen considered included three vaccine doses (at 2 months, 4 months and 6 months) and a booster dose (at 13 months) (3 + 1 schedule). Model outcomes included number of cases prevented, deaths averted, quality-adjusted life-years (QALYs) gained and costs. Discount for costs and benefits of long term sequelae was done at 3.5%, and currency reported in 2008-2009 U$S varying between countries. RESULTS: The largest effect in case prevention was observed in pneumococcal meningitis (from 27% in Peru to 47% in Colombia), neurologic sequelae after meningitis (from 38% in Peru to 65% in Brazil) and bacteremia (from 42% in Argentina to 49% in Colombia). The proportion of predicted deaths averted annually ranged from 18% in Peru to 33% in Brazil. Overall, the health benefits achieved with PHiD-CV vaccination resulted in a lower QALY loss (from 15% lower in Peru to 26% in Brazil). At a cost of USD 20 per vaccine dose, vaccination was cost-effective in all countries, from being cost saving in Chile to a maximum Incremental Cost-effectiveness Ratio of 7,088 US$ Dollars per QALY gained. Results were robust in the sensitivity analysis, and scenarios with indirect costs affected results more than those with herd immunity. CONCLUSIONS: The incorporation of the 10-valent pneumococcal conjugate vaccine into routine infant immunization programs in Latin American countries could be a cost-effective strategy to improve infant population health in the region.

Background: The increasing prevalence of diabetes and its inadequate management results in a heavy burden of the disease for the patients, the health and the productive system and the overall community. Consequently, it is necessary to have new effective drugs to treat people with diabetes to decrease such burden. DPP-4 inhibitors can help to cope with this demand, but its usage is challenged by its apparent high cost. The aim of the current study was to compare a simulated cost-effectiveness ratio of metformin (MET) plus one drug of the DPP-4 inhibitors family, saxagliptin (SAXA) or sulfonylurea (SU) treatment during a 20-year period, from the perspective of the social security system, in a cohort of people with Type 2 diabetes (T2DM) who did not attain glycosylated hemoglobin treatment target values only with MET. Methods: A discrete event simulation model (Cardiff diabetes model) based on UKPDS 68 was used to simulate disease progression and to estimate the economic and health treatment consequences in people with T2DM. The clinical efficacy parameters for SAXA administration were obtained from the literature; local standard costs were considered for drug acquisition, adverse events (AEs), and micro/macrovascular complications. Costs were expressed in US dollars (2009) with an annual 3.5% discount and a 20-year time horizon. Results: The SAXA + MET treated group had a lower number of non-fatal events than the SU + MET treated group. The model also predicted a lower number of fatal macrovascular events for the SAXA + MET group (149.6 vs. 152.8). The total cost of the SAXA + MET cohort was 15% higher than that of the SU + MET cohort. Treatment with SAXA + MET resulted in a higher number of quality-adjusted life years (QALYs) (9.54 vs. 9.32) and life-years gained (LYGs) (20.84 vs. 20.76) compared to those treated with SU + MET. The incremental cost per QALY and LYG gained was $7,374 and $20,490, respectively. Conclusions: According to the criteria proposed by the Commission on Macroeconomics and Health, the use of the combination SAXA+ MET is highly cost-effective in Argentina., Centro de Endocrinología Experimental y Aplicada

Objectives: Cardiac resynchronization therapy (CRT) has recently been shown to reduce both mid-term and long-term mortality in patients with mild heart failure. Although proven effective, it is unclear whether CRT is cost-effective in low and middle-income countries (LMIC). Therefore, we set out to analyze the cost-effectiveness of CRT in Argentina in patients with New York Heart Association (NYHA) functional class (FC) I or II heart failure (HF). We chose to compare patients receiving optimal medical treatment (OMT) and CRT with those patients receiving only OMT.Methods: We constructed a Markov model with a cohort simulation, and a life-time horizon to assess costs, life-years, and quality-adjusted life-year (QALY) gained as a result of treatment with both CRT and OMT from an Argentine third party payer perspective. We included patients who met the following criteria: left ventricular ejection fraction (LVEF) ≤ 40 percent, sinus rhythm with a QRS ≥ 120 msec, and NYHA FC I-II HF. The results were expressed as cost per life-year and QALY gained in international dollars (ID$) for the year 2009.Results: For the base case analysis performed, we started at a fixed age of 65. After applying a 3 percent annual discount rate, the incremental cost-effectiveness ratio (ICER) was 38.005 ID$ per year of life gained and 34.185 ID$ per QALY gained.Conclusions: Long-term treatment with CRT appears to be cost-effective in Argentina compared with patients treated solely with OMT. Similar analysis should be performed to determine if this treatment option is cost-effective in other LMIC.

The present study estimates the economic burden associated with the cases of dengue recorded during the 2009 Argentine epidemic. Among the costs considered are the medical costs necessary for the treatment of those affected and the opportunity costs for those who stopped working or studying because of the disease. In order to assess the costs of the disease, at the end of 2009 an ad-hoc survey was carried out in 201 households where people that had contracted dengue during the 2009 epidemic lived. The results allow us to estimate between 26 to 40 million Argentine pesos (6 to 9 million US dollars) as the total cost of the recorded cases. The regions in the north of Argentina bore the highest economic burden of the disease (more than 90% of the total burden). For all regions, the social cost of one dengue case accounts for more than 40% of the average monthly net individual income.

El Análisis de Impacto Presupuestario (AIP) en el campo de la salud puede ser definido como la estimación de los costos financieros netos que le representarían a una institución dar cobertura a una determinada intervención. En la práctica, los AIP se utilizan frecuentemente para decidir la inclusión o exclusión de medicamentos en formularios terapéuticos y notoriamente han obligado a reconocer que las Evaluaciones Económicas representan una mirada parcial en el análisis de las consecuencias de la incorporación de tecnologías sanitarias. Este trabajo procura identificar los determinantes y componentes de los análisis de impacto presupuestario, y a partir de ello describir el desarrollo de un modelo creado en una planilla de cálculo que permite considerar cualquier tecnología sanitaria y obtener estimaciones con diferentes grados de complejidad. Su diseño incorpora de forma explícita las habilidades del usuario y las deficiencias de información, buscando a su vez promover el desarrollo de estas herramientas en los ámbitos de gestión de nuestros países. Budgetary Impact Analysis (BIA) applied to health care can be defined as the estimate of the net financial costs that a given intervention would represent for a health care institution given the case it was covered. Routinely, BIAs are used to decide the inclusion or exclusion of drugs in therapeutic schemes; actually, the increased use of BIAs have raised awareness about the fact that health economic evaluations represent a partial view in the analysis of the consequences of incorporating health technologies. This paper seeks to identify the determinants and components of BIA, and to describe the development of a spreadsheet model that enables us to assess the Budget impact of any health technology and perform estimations with differing degrees of complexity. Its design explicitly adapts to the user skills and gaps in information, thus seeking to promote the development of these tools in the management fields in our countries.

This paper estimates the annual direct medical and caregiver costs of Streptococcus pneumoniae (Sp) and nontypeable Haemophilus influenzae (NTHi)-associated diseases in children younger than 10 years in Canada, Germany, Mexico, and Norway after vaccination with the 7-valent pneumococcal conjugate vaccine (PCV-7). Per-episode direct medical costs for treating Sp- and NTHi-associated diseases were summarised from the literature for three countries, and a Delphi panel was used to estimate resource use and the per-episode costs for Mexico. Per-episode or annual costs were inflated to 2008 local currency and converted to 2008 United States (US) dollars using purchasing power parities. The analysis was for 1 year; therefore, costs were not discounted. Sp- and NTHi-associated diseases resulted in current annual national costs of $179-$260 million ($5.43-$7.89 per capita) in Canada, $290-$435 million ($3.53-$5.29 per capita) in Germany, $277-$432 million ($2.59-$4.05 per capita) in Mexico, and $20-$28 million ($4.35-$6.17 per capita) in Norway. Although acute otitis media (AOM) was associated with the lowest per-case costs, it accounted for between 45% and 88% of the national direct medical costs and between 67% and 96% of caregiver costs for Sp- and NTHi-associated diseases. Sp- and NTHi-associated diseases continue to result in substantial direct medical and caregiver costs despite current PCV-7 vaccination programs.

Economic evaluation guidelines are widespread in developed countries with fourth hurdle systems but as of yet not in Latin America. In the present article, a systematic search was conducted in order to retrieve regional guidelines in PubMed, Latin American and Caribbean Health Sciences Literature (LILACS) and the gray literature. Four national guidelines were found: Brazil, Colombia, Cuba and Mexico. We report a thorough review of these documents, as well as a comparison among them. We conclude that, despite some differences found, they are broadly similar, and are broadly in accordance with international documents. The existence of these documents, together with other experiences in the region that explicitly use economic evaluation information for health decision making clearly shows that this global tendency is gaining momentum in Latin America, although there is still a long way to go. In the near future we will be able to see if these documents were successfully used and applied for transparent and evidence-based decision making.

Background. Cardiovascular disease (CVD) is the primary cause of mortality and morbidity in Argentina representing 34.2% of deaths and 12.6% of potential years of life lost (PYLL). The aim of the study was to estimate the burden of acute coronary heart disease (CHD) and stroke and the cost-effectiveness of preventative population-based and clinical interventions. Methods. An epidemiological model was built incorporating prevalence and distribution of high blood pressure, high cholesterol, hyperglycemia, overweight and obesity, smoking, and physical inactivity, obtained from the Argentine Survey of Risk Factors dataset. Population Attributable Fraction (PAF) of each risk factor was estimated using relative risks from international sources. Total fatal and non-fatal events, PYLL and Disability Adjusted Life Years (DALY) were estimated. Costs of event were calculated from local utilization databases and expressed in international dollars (I$). Incremental cost-effectiveness ratios (ICER) were estimated for six interventions: reducing salt in bread, mass media campaign to promote tobacco cessation, pharmacological therapy of high blood pressure, pharmacological therapy of high cholesterol, tobacco cessation therapy with bupropion, and a multidrug strategy for people with an estimated absolute risk > 20% in 10 years. Results. An estimated total of 611,635 DALY was lost due to acute CHD and stroke for 2005. Modifiable risk factors explained 71.1% of DALY and more than 80% of events. Two interventions were cost-saving: lowering salt intake in the population through reducing salt in bread and multidrug therapy targeted to persons with an absolute risk above 20% in 10 years; three interventions had very acceptable ICERs: drug therapy for high blood pressure in hypertensive patients not yet undergoing treatment (I$ 2,908 per DALY saved), mass media campaign to promote tobacco cessation amongst smokers (I$ 3,186 per DALY saved), and lowering cholesterol with statin drug therapy (I$ 14,432 per DALY saved); and one intervention was not found to be cost-effective: tobacco cessation with bupropion (I$ 59,433 per DALY saved). Conclusions. Most of the interventions selected were cost-saving or very cost-effective. This study aims to inform policy makers on resource-allocation decisions to reduce the burden of CVD in Argentina., Centro de Endocrinología Experimental y Aplicada (CENEXA)

Aim: To compare clinical-metabolic monitoring and coronary risk status in people with type 2 diabetes from Australia, France and Latin America. Methods: Retrospective analysis of data collected at primary care (4540 participants from each population) matched for age, gender and disease duration. Measurements included participants' characteristics, performance frequency of clinical-metabolic process indicators, and percentage of clinical-metabolic outcomes at recommended target values. Results: The weighted mean of the percentage of process performance was within 68 to 81%; that of outcomes at target dropped to 29 to 45%. Although statistically significant, differences among groups were far from those in healthcare budgets, and probably only of marginal clinical impact. The percentage of patients with low, slight or high coronary risk was similar in the three groups, with most people at high or very high risk. Conclusions: Despite the high difference in health per capita investment and system characteristics among countries, the study populations had striking similarities regarding the low percentage of participants who achieved cardiovascular risk factor and diabetes treatment goals. Therefore, differences in health budget and system characteristics would not be the main drivers in care quality. Diabetes education at every level and quality care registries would contribute to improve this situation and assess such improvement. Fil: Gagliardino, Juan Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico La Plata. Centro de Endocrinología Experimental y Aplicada (i); Argentina Fil: Kleinebreil, Line. Hopital Europeen Georges Pompidou; Francia Fil: Colagiuri, Stephen. Prince Of Wales Hospital; Australia Fil: Flack, Jeff. Prince Of Wales Hospital; Australia Fil: Caporale, Joaquín E.. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico La Plata. Centro de Endocrinología Experimental y Aplicada (i); Argentina Fil: Siri, Fernando. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico La Plata. Centro de Endocrinología Experimental y Aplicada (i); Argentina Fil: Clark Jr., Charles. Indiana University School of Medicine; Estados Unidos

Objetivo. Estimar la carga de la enfermedad, su proporción atribuible a los principales factores de riesgo cardiovascular modificables y los costos médicos directos por hospitalización, asociados con las enfermedades coronarias y los accidentes cerebrovasculares en Argentina. Métodos. Se elaboró un modelo analítico a partir de los datos de mortalidad en Argentina en 2005 y la prevalencia de los principales factores de riesgo cardiovascular (hipertensión arterial, hipercolesterolemia, sobrepeso, obesidad, hiperglucemia, tabaquismo actual y pasado, sedentarismo y consumo inadecuado de frutas y verduras). Se estimaron la carga de la enfermedad —años potenciales de vida perdidos (APVP) y años de vida saludable (AVISA) perdidos— y los costos de hospitalización por las enfermedades cardiovasculares analizadas. Resultados. En 2005 se perdieron en Argentina más de 600 000 AVISA y se contabilizaron casi 400 000 APVP por enfermedades coronarias y accidentes cerebrovasculares; 71,1 % de los AVISA perdidos, 73,9% de APVP y 76,0% de los costos asociados son atribuibles a factores de riesgo modificables. La hipertensión arterial fue el factor de riesgo de mayor impacto, tanto en hombres como en mujeres: 37,3% del costo total, 37,5% de los APVP y 36,6% de los AVISA perdidos. Conclusiones. La mayor parte de la carga de la enfermedad en Argentina por enfermedades cardiovasculares está relacionada con factores de riesgo modificables —por lo tanto evitables— y podría reducirse mediante intervenciones poblacionales y clínicas basadas en un enfoque de riesgo, que ya han demostrado ser efectivas en función del costo, asequibles y factibles en países como Argentina., Objective. Estimate the burden of disease, the proportion attributable to the principal modifiable cardiovascular risk factors, and the direct medical cost of hospitalizaEstimate of the cardiovascular disease burden attributable to modifiable risk factors in Argentina tion associated with coronary heart disease and stroke in Argentina. Methodology. An analitical model was prepared using Argentina's 2005 mortality data and the prevalence of the principal cardiovascular risk factors (hypertension, hypercholesterolemia, overweight, obesity, hyperglycemia, current and past smoking, sedentary lifestyle, and inadequate intake of fruits and vegetables). The burden of disease—years of potential life lost (YPLL) and years of healthy life lost (YHLL)— and hospitalization costs for the cardiovascular diseases analyzed were estimated. Results. In 2005 over 600 000 YHL were lost in Argentina and the number of YPLL due to heart disease and stroke was calculated at 400 000; 71.1% of the YHLL, 73.9% of the YPLL, and 76.0% of the associated costs were attributable to modifiable risk factors. Hypertension was the risk factor with the greatest impact in both men and in women, responsible for 37.3% of the total cost, 37.5% of the YPLL, and 36.6% of the YHLL. Conclusions. Most of the burden of disease from cardiovascular disease in Argentina is associated with modifiable, and therefore preventable, risk factors and could be reduced through population-based and clinical interventions that employ a risk approach; such interventions have already proven to be cost effective, accessible, and feasible in countries like Argentina., Facultad de Ciencias Médicas

Estimate the burden of disease, the proportion attributable to the principal modifiable cardiovascular risk factors, and the direct medical cost of hospitalization associated with coronary heart disease and stroke in Argentina.An analitical model was prepared using Argentina's 2005 mortality data and the prevalence of the principal cardiovascular risk factors (hypertension, hypercholesterolemia, overweight, obesity, hyperglycemia, current and past smoking, sedentary lifestyle, and inadequate intake of fruits and vegetables). The burden of disease-years of potential life lost (YPLL) and years of healthy life lost (YHLL)- and hospitalization costs for the cardiovascular diseases analyzed were estimated.In 2005 over 600 000 YHL were lost in Argentina and the number of YPLL due to heart disease and stroke was calculated at 400 000; 71.1% of the YHLL, 73.9% of the YPLL, and 76.0% of the associated costs were attributable to modifiable risk factors. Hypertension was the risk factor with the greatest impact in both men and in women, responsible for 37.3% of the total cost, 37.5% of the YPLL, and 36.6% of the YHLL.Most of the burden of disease from cardiovascular disease in Argentina is associated with modifiable, and therefore preventable, risk factors and could be reduced through population-based and clinical interventions that employ a risk approach; such interventions have already proven to be cost effective, accessible, and feasible in countries like Argentina.

Objetivo. Analizar los costos de atención ambulatoria de personas con diabetes hospitalizadas por causas relacionadas con esta enfermedad —anteriores o posteriores a la hospitalización— y compararlos con los de personas diabéticas que no fueron hospitalizadas durante el mismo período. Métodos. Determinamos los gastos de atención hospitalaria y ambulatoria de personas con diabetes afiliadas a una empresa argentina de medicina prepaga que habían sido hospitalizadas durante el período de estudio y comparamos estos últimos con los de afiliados diabéticos que no habían sido hospitalizados durante dicho período. Resultados. Identificamos 2 760 personas con diabetes (2,4% del total de afiliados a la empresa de medicina prepaga); de ellas, 1 683 (59%) trataban la diabetes y los factores de riesgo cardiovascular asociados con medicación específica; la diabetes se asociaba con uno (41%) o dos (24%) factores de riesgo cardiovascular. De estas 1 683 personas, 102 (6%) fueron hospitalizadas por causas relacionadas con la diabetes durante el período estudiado; la frecuencia de hospitalización aumentó significativamente cuando la diabetes se asociaba con hipertensión arterial y dislipidemia. La enfermedad cardiovascular originó el 43,1% de las hospitalizaciones, con un costo per capita significativamente mayor que el registrado por otras causas (media ± error estándar de la media [1 673 ± 296,8] dólares estadounidenses [US$]; P < 0,05). Los costos totales anuales per capita de atención de las personas que fueron hospitalizadas resultaron mayores que los relativos a las que no fueron hospitalizadas (US$ [2 907,8 ± 262,5] frente a US$ [473,4 ± 9,8], respectivamente; P < 0,01). Los costos totales de atención ambulatoria posteriores a la hospitalización fueron un 12% mayores que los del período anterior a la hospitalización (US$ [903,6 ± 108,6] frente a US$ [797,6 ± 14,9]; diferencia no significativa). Conclusión. Los costos de atención ambulatoria aumentan significativamente en el período anterior y posterior a la hospitalización. Los resultados obtenidos sugieren que el tratamiento intensivo de la hiperglucemia y de los factores de riesgo cardiovascular asociados puede prevenir hospitalizaciones con un costo menor que el de la hospitalización y la atención ambulatoria durante el período posthospitalario., Objective. To analyze and compare the ambulatory care expenditures for persons with diabetes during prehospitalization and posthospitalization periods with those of diabetics who were not hospitalized for diabetes-related illnesses during the same period. Methods. We determined the hospitalization and ambulatory care expenses incurred by an Argentine health insurer for the hospitalization of diabetic clients during the study period, and compared these expenses to the expenses of insured diabetics who were not hospitalized during that period. Results. We identified 2 760 persons with diabetes (2.4% of the total number of persons covered by the insurance company). Of those, 1 683 (59%) were on medication for diabetes and its associated cardiovascular risk factors. Diabetes was associated with either one (41%) or two (24%) cardiovascular risk factors. Of those 1 683 persons, 102 (6%) were hospitalized for diabetes-related reasons during the study period. The frequency of hospitalization increased significantly in cases where diabetes was associated with arterial hypertension and dyslipidemia. Cardiovascular illness was the cause of 43.1% of the hospitalizations, with a significantly higher per capita cost than any of the other causes identified (mean ± standard error of the mean: US$ 1 673 ± US$ 296.8; P < 0.05). The total annual per capita cost for health care for the diabetics who had been hospitalized was greater than for those who had not (US$ 2 907.8 ± US$ 262.5 compared to US$ 473.4 ± US$ 9.8, respectively; P < 0.01). While the total posthospitalization ambulatory care expenditures were 12% higher than the prehospitalization costs (US$ 903.6 ± US$ 108.6 vs. US$ 797.6 ± US$ 14.9), the difference was not significant. Conclusion. Ambulatory care expenditures increase significantly in the prehospitalization and posthospitalization periods. The results suggest that intensive treatment of hyperglycemia and its associated cardiovascular risk factors may prevent hospitalization and is a more cost-effective option than hospitalization and posthospitalization ambulatory care., Facultad de Ciencias Médicas