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- Adverse drug reactions in hospitals: population estimates for Portugal and the ICD-9-CM to ICD-10-CM crosswalkPublication . Ascenção, Raquel; Nogueira, Paulo Jorge; Sampaio, Filipa; Henriques, Adriana; Costa, AndreiaBackground: Adverse drug reactions (ADR), both preventable and non-preventable, are frequent and pose a significant burden. This study aimed to produce up-to-date estimates for ADR rates in hospitals, in Portugal, from 2010 to 2018. In addition, it explores possible pitfalls when crosswalking between ICD-9-CM and ICD-10-CM code sets for ADR identification. Methods: The Portuguese Hospital Morbidity Database was used to identify hospital episodes (outpatient or inpatient) with at least one ICD code of ADR. Since the study period spanned from 2010 to 2018, both ICD-9-CM and ICD-10-CM codes based on previously published studies were used to define episodes. This was an exploratory study, and descriptive statistics were used to provide ADR rates and summarise episode features for the full period (2010-2018) as well as for the ICD-9-CM (2010-2016) and ICD -10-CM (2017-2018) eras. Results: Between 2010 and 2018, ADR occurred in 162,985 hospital episodes, corresponding to 1.00% of the total number of episodes during the same period. Higher rates were seen in the oldest age groups. In the same period, the mean annual rate of episodes related to ADR was 174.2/100,000 population. The episode rate (per 100,000 population) was generally higher in males, except in young adults (aged '15-20', '25-30' and '30-35' years), although the overall frequency of ADR in hospital episodes was higher in females. Conclusions: Despite the ICD-10-CM transition, administrative health data in Portugal remain a feasible source for producing up-to-date estimates on ADR in hospitals. There is a need for future research to identify target recipients for preventive interventions and improve medication safety practices in Portugal.
- The current and future burden of heart failure in PortugalPublication . Gouveia, Miguel; Ascenção, Raquel; Fiorentino, Francesca; Costa, João; Caldeira, Daniel; Broeiro-Gonçalves, Paula; Fonseca, Candida; Borges, MargaridaAIMS: Heart failure (HF) is a clinical syndrome with significant social and economic burden. We aimed to estimate the burden of HF in mainland Portugal over a 22-year time horizon, between 2014 and 2036. METHODS AND RESULTS: Heart failure burden was measured in disability-adjusted life years (DALYs), resulting from the sum of years of life lost (YLL) due to premature death and years lost due to disability (YLD). YLL were estimated based on the Portuguese mortality rates reported by the European Detailed Mortality Database. For YLD, disease duration and the overall incidence were estimated using an epidemiological model developed by the World Health Organization (DISMOD II). Disability weights were retrieved from published literature. The impact of ageing was estimated with a shift-share analysis using official demographic projections. In 2014, 4688 deaths were attributed to HF, corresponding to 4.7% of the total deaths in mainland Portugal. DALYs totalled 21 162, 53.9% due to premature death (YLL: 11 398) and 46.1% due to disability (YLD: 9765). Considering only population ageing over a 22-year horizon, the deaths and burden of HF are expected to increase by 73.0% and 27.9%, respectively, reaching 8112 deaths and 27 059 DALYs lost due to HF in 2036. DALY's growth is mainly driven by the increase of YLL, whose contribution to overall burden will increase to 62.0%. CONCLUSIONS: Heart failure is an emerging and growing health problem where significant health gains may be obtained. The projected significant increase of HF burden highlights the need to set HF as a priority for healthcare system.
- O custo e a carga da esquizofrenia em Portugal em 2015Publication . Gouveia, Miguel; Ascenção, Raquel; Fiorentino, Francesca; Pascoal, João; Costa, João; Borges, MargaridaIntrodução: A esquizofrenia é uma importante causa de incapacidade e consumo de recursos económicos. Neste estudo pretendemos estimar os custos e a carga da esquizofrenia para 2015 em Portugal Continental. Métodos: A carga da doença foi medida pelos anos de vida ajustados pela incapacidade (DALY- Disability-adjusted life years), uma métrica adotada pela Organização Mundial de Saúde. O custo da doença foi estimado com base na prevalência adotando a perspetiva global da sociedade. Os custos incluíram os consumos de recursos e os custos indiretos dos doentes e cuidadores (perdas de produtividade). As principais fontes de informação de custos foram: a base de dados GDH; os contratos programa; dados de consumo de medicamentos e opinião de peritos. Resultados: A prevalência da esquizofrenia será cerca de 48 mil doentes, sendo que o número de doentes seguidos pelo sistema de saúde (público e privado) deverá estar na ordem dos 41 mil doentes. Em 2015, estima-se que se tenham perdido 28.588 DALY (84% por incapacidade; 16% por mortalidade prematura). A preços de 2015, o total estimado de custos diretos e indiretos da esquizofrenia foi respetivamente de € 96,1 e € 340,3 milhões (97% gerados pelos doentes). Conclusão: A esquizofrenia tem um importante impacto social em Portugal devido essencialmente à morbilidade gerada, podendo-se-lhe atribuir em 2015 um custo total de € 436,3 milhões, cerca de 0,24% do produto interno bruto. Os custos diretos representam 0,6 % de todas as despesas de saúde em 2015, enquanto a totalidade dos custos (diretos e indiretos) representam 2,7% da despesa em saúde.
- In-hospital mortality of high-risk pulmonary embolism: a nationwide population-based cohort study in Portugal from 2010 to 2018Publication . Calé, R.; Ascenção, Raquel; Bulhosa, C.; Pereira, Helder; Borges, Margarida; Costa, J.; Caldeira, DanielBackground: The mortality associated with high-risk pulmonary embolism (PE) is remarkably high, and reperfusion to unload right ventricle should be a priority. However, several registries report reperfusion underuse. In Portugal, epidemiological data about the incidence, rate of reperfusion and mortality of high-risk PE are not known. Methods: Nationwide population-based temporal trend study in the incidence and outcome of high-risk PE, who were admitted to hospitals of the National Health Service in Portugal between 2010 and 2018. High-risk PE was defined as patients with PE who developed cardiogenic shock or cardiac arrest. International Classification of Diseases (ICD), 9th and 10th revision, Clinical Modification codes, were used for data from the period between 2010 and 2016 (ICD-9-CM) and 2017-2018 (ICD-10-CM), respectively. The assessment focused on trends in the use of reperfusion treatment, which was defined by application of thrombolysis or pulmonary embolectomy. A comparison was made between the use or non-use of reperfusion therapy in order to examine trends in in-hospital mortality among high-risk PE cases. Results: From 2010 and 2018, there were 40.311 hospitalization episodes for PE in adult patients at hospitals of the National Health Service in mainland Portugal. There was a significant increase in the annual incidence of PE (41/100.000 inhabitants in 2010 to 46/100.000 in 2018; R2=0.582, p = 0.010). The average annual incidence was 45/100.000 inhabitants/year, with 2,7% of the PE episodes (1104) categorized as high-risk. The mortality rate associated with high-risk PE was high, although it has decreased over the years (74.2% in 2010 to 63.6% in 2018; R2=0.484; p = 0.022). Thrombolytic therapy was underused in high-risk PE, and its usage has not increased in recent years (17.3% in 2010 to 21.1% in 2018, R2=-0.127; p = 0.763). Surgical pulmonary embolectomy was used in 0.27% of cases, and there was no registry of catheter-directed thrombolysis. Patients with high-risk PE undergoing reperfusion therapy had lower in-hospital mortality compared to non-reperfused patients (OR=0.52; IC95% 0.38-0.70). Conclusion: In Portugal, between 2010 and 2018, very few patients with PE developed high-risk forms of the disease, but the mortality rate among those patients was high. The low reperfusion rate could be associated with high in-hospital mortality and highlights the need to implement advanced therapies, as an alternative to systemic thrombolysis.
- The epidemiology of falls in Portugal: an analysis of hospital admission dataPublication . Sampaio, Filipa; Nogueira, Paulo Jorge; Ascenção, Raquel; Henriques, Adriana; Costa, AndreiaBackground: Falls are a common cause of injury and pose an increased risk of morbidity, mortality, and lifelong disability. Falls encompass a troublesome definition and can pose challenges in epidemiological studies. Data on fall-related hospital admissions in Portugal remain unpublished. This study aimed to examine the epidemiology of fall-related hospital admissions in the Portuguese population between 2010 and 2018. It also aimed to examine annual rates of fall-related hospital admissions using three methodological approaches. Methods: The Portuguese Hospital Morbidity Database was used to identify all cases resulting in one or more inpatient admission in public hospitals related to falls from 2010 to 2018. Fall-related hospital admissions were described by age groups, sex, geographical area of residence, and type of fall. Annual rates were computed using three approaches: i) based on the number of inpatient admissions with an ICD code of fall, ii) based on the number of patients admitted to inpatient care with an ICD code of fall, and iii) based on the number of inpatient admissions with a principal diagnosis of injury. Results: Between 2010 and 2018, 383,016 fall-related admissions occurred in 344,728 patients, corresponding to 2.1% of the total number of hospitalizations during the same period. Higher rates were seen among the younger (20-25) and the oldest age groups (+85), males until the age of 60, females from the age of 60, and areas of residence with a higher aging index. An overall rate of falls per 100,000 population was estimated at 414 (based on number of admissions), 373 (based on number of patients) and 353 (based on number of admissions with a principal diagnosis of injury). Conclusions: This study provides an overall picture of the landscape of falls in a scarcely explored setting. The results aim to contribute to identifying appropriate preventive interventions and policies for these populations.
- Trainees as simulated patients in family medicine/general practice OSCE stations for undergraduate students: unintended (positive) consequencesPublication . Ascenção, Raquel; Afonso, David; Lopes, Sandra; Carmo, Pedro; Coelho, Inês; Coelho e Silva, Sara; Gaspar, Catarina; Gonçalves Gaspar, Ivone; Fortuna, Luís; Morais Lopes, Margarida; Nina, Ana Sofia; Pereira, Luísa; Pitta, Rita; Proença-Portugal, Mafalda; Silva, Alda Pereira daIn our medical school, an OSCE was recently introduced as a high-stakes exam in the 4th year. For the first time, Family Medicine/General Practice (FM/GP) faculty members were involved in such a complex undertaking, being responsible for two of the ten five-minute stations. Facing limited resources, we decided to invite FM/GP trainees as simulated patients (SP). They were provided with a ninety minute training session prior to the OSCE. In our debriefing session, examiners and SP felt confident in the aftermath. Examiners praised the trainees’ participation for the level of standardisation achieved. On the other hand, SP practitioners felt training was hugely facilitated because of the trainees’ thorough knowledge of ‘typical’ patients. Trainees confided they saw their participation as an opportunity to feel like a patient, enabling the development of empathy, and recognise the impact of different communication skills in the doctor-patient relationship. This was vastly unforeseen for the faculty members and perceived as a silver lining.
- Clinical comparability of the new antiepileptic drugs in refractory partial epilepsy : a systematic review and meta-analysisPublication . Costa, João; Fareleira, Filipa; Ascenção, Raquel; Borges, Margarida; Sampaio, Cristina; Carneiro, António VazPurpose: Evaluate the clinical comparability of new antiepileptic drugs (AEDs) in partial refractory epilepsy. Methods: Systematic review of randomized trials (RCTs) comparing a new AED (add-on treatment) with placebo or another AED. Primary outcomes: responder (≥50% seizure reduction) and withdrawal (tolerability) rates. Pooled estimates of odds ratios (ORs) and number needed treat/harm (NNT/NNH) taking into account baseline risk were derived by random-effects meta-analysis. Adjusted frequentist indirect comparisons between AEDs were estimated. Key Findings: Sixty-two placebo-controlled (12,902 patients) and eight head-to-head RCTs (1,370 patients) were included. Pooled ORs for responder and withdrawal rates (vs. placebo) were 3.00 [95% confidence interval (CI) 2.63–3.41] and 1.48 (1.30–1.68), respectively. Indirect comparisons of responder rate based on relative measurements of treatment effect (ORs) favored topiramate (1.52; 1.06–2.20) in comparison to all other AEDs, whereas gabapentin (0.67; 0.46–0.97) and lacosamide (0.66; 0.48–0.92) were less efficacious, without significant heterogeneity. When analyses were based on absolute estimates (NNTs), topiramate and levetiracetam were more efficacious, whereas gabapentin and tiagabine were less efficacious. Withdrawal rate was higher with oxcarbazepine (OR 1.60; 1.12–2.29) and topiramate (OR 1.68; 1.07–2.63), and lower with gabapentin (OR 0.65; 0.42–1.00) and levetiracetam (OR 0.62; 0.43–0.89). Significance: The differences found are of relatively small magnitude to allow a definitive conclusion about which new AED(s) has superior effectiveness. This uncertainty probably reflects the limitations of conclusions based on indirect evidence. The process of pharmacologic clinical decision making in partial refractory epilepsy probably depends more on other aspects, such as individual patient characteristics and pharmacoeconomics, than on available controlled randomized evidence.
- Os custos da insuficiência cardíaca em Portugal e a sua evolução previsível com o envelhecimento da populaçãoPublication . Gouveia, Miguel Rebordão de Almeida; Ascenção, Raquel; Fiorentino, Francesca; Costa, João; Broeiro-Gonçalves, Paula; Fonseca, Maria Cândida Faustino Gamito da; Borges, MargaridaIntroduction and Objectives: Heart failure (HF) is a growing public health problem. This study estimates the current and future costs of HF in mainland Portugal. Methods: Costs were estimated based on prevalence and from a societal perspective. The annual costs of HF included direct costs (resource consumption) and indirect costs (productivity losses). Estimates were mostly based on data from the Diagnosis-Related Groups database, real-world data from primary care, and the opinions of an expert panel. Costs were estimated for 2014 and, taking population aging into account, changes were forecast up to 2036. Results: Direct costs in 2014 were D 299 million (39% for hospitalizations, 24% for medicines, 17% for exams and tests, 16% for consultations, and the rest for other needs, including emergencies and long-term care). Indirect costs were D 106 million (16% for absenteeism and 84% for reduced employment). Between 2014 and 2036, due to demographic dynamics, total costs will increase from D 405 to D 503 million. Per capita costs are estimated to rise by 34%, which is higher than the increase in total costs (+24%), due to the expected reduction in the resident population. Conclusions: HF currently has a significant economic impact, representing around 2.6% of total public health expenditure, and this is expected to increase in the future. This should be taken into account by health policy makers, alerting them to the need for resource management in order to mitigate the impact of this disease.
- Atherosclerosis in the primary health care setting: a real-word data studyPublication . Ascenção, Raquel; Alarcão, Joana; Araujo, Francisco; Costa, João; Fiorentino, Francesca; Gil, Victor; Gouveia, Miguel; Lourenço, Francisco; Mello e Silva, Alberto; Carneiro, António Vaz; Borges, MargaridaIntroduction and objectives: To characterize patients with atherosclerosis, a disease with a high socioeconomic impact, in the Lisbon and Tagus Valley Health Region. Methods: A cross-sectional observational study was carried out through the Lisbon and Tagus Valley Regional Health Administration primary health care database, extracting data on the clinical and demographic characteristics and resource use of adult primary health care users with atherosclerosis during 2016. Different criteria were used to define atherosclerosis (presence of clinical manifestations, atherothrombotic risk factors and/or consumption of drugs related to atherosclerosis). Comparisons between different subpopulations were performed using parametric tests. Results: A total of 318 692 users were identified, most of whom (n=224 845 users; 71%) had no recorded clinical manifestations. The subpopulation with clinical manifestations were older (72.0±11.5 vs. 71.3±11.0 years), with a higher proportion of men (58.0% vs. 45.9%), recorded hypertension (78.3% vs. 73.5%) and dyslipidemia (55.8% vs. 53.5%), and a lower proportion of recorded obesity (18.2% vs. 20.8%), compared to those without clinical manifestations (p<0.001). Mean blood pressure, LDL-C and glycated hemoglobin values were lower in the subpopulation with manifestations (142/74 vs. 146/76 mmHg, 101 vs. 108 mg/dl, and 6.80 vs. 6.84%, respectively; p<0.001). Each user with atherosclerosis attended 4.1±2.9 face-to-face medical consultations and underwent 8.6±10.0 laboratory test panels, with differences in subpopulations with and without clinical manifestations (4.4±3.2 vs. 4.0±2.8 and 8.3±10.3 vs. 8.7±9.8, respectively; p<0.001). Conclusions: About one in three adult primary health care users with atherosclerosis have clinical manifestations. The results suggest that control of cardiovascular risk factors is suboptimal in patients with atherosclerosis.
- The burden of atherosclerosis in PortugalPublication . Costa, João; Alarcão, Joana; Araujo, Francisco; Ascenção, Raquel; Caldeira, Daniel; Fiorentino, Francesca; Gil, Victor; Gouveia, Miguel; Lourenço, Francisco; Mello e Silva, Alberto; Sampaio, Filipa; Carneiro, António Vaz; Borges, MargaridaAims: This paper sought to estimate the burden of disease attributable to atherosclerosis in mainland Portugal in 2016. Methods and results: The burden of atherosclerosis was measured in disability-adjusted life years (DALY) following the latest 2010 Global Burden of Disease (GBD) methodology. DALYs were estimated as the sum of years of life lost (YLL) with years lived with disability (YLD). The following clinical manifestations of atherosclerosis were included: ischemic heart disease (IHD) (including acute myocardial infarction (AMI), stable angina, and ischemic heart failure (IHF)), ischemic cerebrovascular disease (ICVD) and peripheral arterial disease (PAD). YLL were estimated based on all-cause mortality data for the Portuguese population and mortality due to IHD, ICVD and PAD for the year 2016 sourced from national statistics. Standard life expectancy was sourced from the GBD study. YLD corresponded to the product of the number of prevalent cases by an average disability weight (DW) for all possible combinations of disease. Prevalence data for the different clinical manifestations of atherosclerosis were sourced from epidemiological studies. DW were sourced from the published literature. In 2016, 15,123 deaths were attributable to atherosclerosis, which corresponded to 14.3% of overall mortality in mainland Portugal. DALYs totaled 260,943, 75% due to premature death (196,438 YLL) and 25% due to disability (64,505 YLD). Conclusion: Atherosclerosis entails a high disease burden to society. A large part of this burden would be avoidable if evidence-based effective and cost-effective interventions targeting known risk factors, from prevention to treatment, were implemented.