Augusto Afonso Guerra Júnior

Federal University of Minas Gerais, Cidade de Minas, Minas Gerais, Brazil

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Publications (19)10.57 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: The costs of the insulin analogue (insulin glargine) have been growing appreciably in the State of Minas Gerais in Brazil, averaging 291 % per year in recent years. This growth has been driven by an increasing number of successful law suits and a 536 % price difference between insulin glargine and neutral protamine Hagedorn (NPH) insulin. One potential way to address this is to undertake a systematic review assessing the efficacy and safety of insulin glargine analogue compared with NPH insulin in patients with type 1 diabetes mellitus (T1DM), and, as a result, provide published data to support future recommended activities by the State of Minas Gerais. These could include maintaining it on the list of the Public Health System (SUS) provided there is a price reduction. Alternatively, the review could provide potential arguments to defend against future law suits should the authorities decide to delist insulin glargine. A systematic review of published studies researching the effectiveness of insulin glargine in patients with T1DM between January 1970 and July 2009 in MEDLINE (PubMed), the Latin American and Caribbean Centre on Health Sciences Information, the Cochrane Controlled Trials Databases and the National Health Service Centre for Reviews and Dissemination. Inclusion criteria included insulin glargine on its own or combined with other insulin formulations. Only randomised controlled clinical trials were included. Initially, the titles of all studies were assessed by two independent reviewers before being potentially discarded, with the quality of papers assessed using a modified Jadad scale. The outcome measures included blood levels of glycated haemoglobin, episodes of hypoglycaemia, adverse effects and the reduction of microvascular and macrovascular end-organ complications of T1DM. Out of 803 studies found in the selected databases, only eight trials met the inclusion criteria. Most of the studies were of poor methodological quality or had a high risk of bias, with a mean score of 2.125 on the Jadad scale. No study could be classified as double-blind, and only one study documented the increased efficacy of insulin glargine in relation to both glycaemic control and hypoglycaemic episodes. Typically, there was no significant difference between insulin glargine and NPH insulins. This systematic review showed no therapeutic benefit of insulin glargine over other insulin formulations studied when analysing together glycaemic control and the frequency and severity of hypoglycaemia. We therefore recommend to the State Authority to delist insulin glargine or renegotiate a price reduction with the manufacturer. This systematic review provides support for this decision as well as documentation to combat potential law suits if discussions are unsatisfactory.
    Applied Health Economics and Health Policy 01/2014;
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    ABSTRACT: Introduction Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by systemic joint inflammation that often leads to significant disability. Several effective anti–TNF agents have been used, but some patients have shown an inadequate response. Rituximab is a therapeutic monoclonal antibody indicated in such cases. Methods We conducted a systematic review to access efficacy and safety of rituximab in patients with active RA which have or have not been treated with anti–TNF agents before, and to relate outcome with RF and anti–CCP serology. We searched major electronics databases, grey literature and searched for references manually. We used Review Manager®5.1 for meta–analysis. Results We included six RCTs comparing rituximab 1000 mg with placebo. Methotrexate was used by both groups. Treatment with rituximab was more effective in naïve and in anti–TNF treatment failure patients ACR20/50/70 and EULAR response. We observed lower changes in Total Genant–modified Sharp score, erosion score and joint narrowing scores in the rituximab group, and SF–36, FACIT–T and HAQ–DI scores were also better in this group. There were no differences between groups regarding safety outcomes, with exception of acute injection reactions, which were more common on rituximab group. More RF/anti–CCP seropositive patients achieved ACR20 than RF/anti–CP negative patients in rituximab group. Conclusion Available data support the use of rituximab for the treatment of RA, as it is an effective and safe option for naïve and anti–TNF treatment failure patients. RF and anti–CCP seam to influence treatment results, but this inference needs further research.
    Revista Brasileira de Reumatologia 01/2014; 54(3):220–230. · 0.86 Impact Factor
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    ABSTRACT: Introdução A artrite reumatoide (AR) é uma doença autoimune crônica caracterizada por inflamação articular sistêmica que, com frequência, leva a significativa incapacitação. Vários agentes anti-TNF têm sido usados efetivamente, mas alguns pacientes demonstraram resposta inadequada. Rituximabe é um anticorpo monoclonal terapêutico indicado em tais casos. Métodos Realizou-se uma revisão sistemática para avaliar a eficácia e a segurança de rituximabe em pacientes com AR ativa previamente tratados ou não com agentes anti-TNF e para relacionar o desfecho com a sorologia para FR e anti-CCP. Pesquisaram-se importantes bancos de dados eletrônicos e a literatura não convencional, além de se fazer uma busca manual de referências. Para a meta-análise, utilizou-se o programa Review Manager® 5.1. Resultados Consideramos seis ERCs comparando rituximabe 1000 mg com placebo. Em ambos os grupos usou-se Metotrexato. O tratamento com rituximabe foi mais efetivo em pacientes jamais tratados e nos que não obtiveram sucesso com a terapia anti-TNF – critérios ACR 20/50/70 e EULAR. No grupo de rituximabe, observaram-se mudanças menos expressivas nos escores de Sharp/Genant, de erosão e de estreitamento do espaço articular; nesse grupo, os escores SF-36, FACIT-T e HAQ-DI também foram melhores. Não foram notadas diferenças entre grupos com relação aos desfechos de segurança, com exceção das reações agudas à infusão, que foram mais comuns no grupo de rituximabe. Ainda no grupo de rituximabe, um número maior de pacientes soropositivos para FR/anti-CCP alcançou ACR20, em comparação com pacientes negativos para RF/anti-CCP. Conclusão Os dados disponíveis falam em favor do uso de rituximabe para o tratamento da AR, como opção efetiva e segura para pacientes jamais tratados ou que não obtiveram sucesso com o tratamento anti-TNF. FR e anti-CCP parecem influenciar os resultados do tratamento, mas essa inferência ainda está à espera de futuras pesquisas.
    Revista Brasileira de Reumatologia (English Edition). 01/2014; 54(3):220–230.
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    ABSTRACT: To analyze expenditure on treatment for postmenopausal osteoporosis and associated factors on mean per capita expenditure. A probabilistic-deterministic linkage between the database of Authorizations for Highly Complex Procedures and the mortality information system was constructed, resulting in a historical cohort of patients using high-cost medications for the treatment of postmenopausal osteoporosis, between 2000-2006. Mean monthly spending on medicines was stratified by age group and described according to demographic and clinical characteristics and the type of drug used. A linear regression model was used to assess the impact of demographic and clinical characteristics on per capita mean monthly expenditure on medicines. We identified 72,265 women who received drugs for the treatment of postmenopausal osteoporosis. The average monthly expenditure per capita in the first year of treatment was $ 54.02 (sd $ 86.72). The population was predominantly composed of women aged 60-69 years old, who had started treatment in 2000, resident in the Southeast of Brazil, who had previously suffered osteoporotic fractures, and Alendronate sodium was the drug most commonly used at baseline. For most of the patients, the same active ingredient remained in use throughout the treatment period. During the program, 6,429 deaths were identified among participants. More than a third of women remained in treatment for up to 12 months. Raloxifen and calcitonin were the therapeutic alternatives with the greatest impact on the average monthly expenditure on medicine using alendronate sodium as a reference standard. Due to the high impact of the type of drug used on expenditure on medication, it is recommended that criteria for prescribing and dispensing be established by prioritizing those with lower costs and greater effectiveness in order to optimize the process of pharmaceutical care and provide the population with a greater number of pharmaceutical units.
    Revista de saude publica 06/2013; 47(2):390-402. · 1.01 Impact Factor
  • Value in Health 05/2013; 16(3):A128-9. · 2.19 Impact Factor
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    ABSTRACT: This article analyzes the use of medicines by individuals with hypertension and/or diabetes mellitus who received their medication through a public network of pharmacies, with a particular emphasis on gender differences. During the first two months of 2010, individuals with hypertension and/or diabetes were interviewed in half of the 64 municipalities (counties) participating in the Minas Gerais Pharmacy Network. Mean age of the 4,777 interviewees was 60.9 years, which may have contributed to the high mean number of medicines used (4.0 among women and 3.5 among men). The most frequently used drugs were those acting on the cardiovascular system (56.3%), alimentary tract and metabolism (14.9%), and nervous system (13.8%), consistent with the sample's epidemiological profile. Women and more elderly individuals tended to use more medicines. The findings show high expenditures on medicines by the interviewees and suggest the design of educational activities targeting rational use of medication.
    Cadernos de saúde pública / Ministério da Saúde, Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública 08/2012; 28(8):1546-58. · 0.83 Impact Factor
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    ABSTRACT: In Brazil, medicines for treatment of chronic renal failure are available free of cost from the Unified National Health System (SUS). This study's objectives were to describe government spending on these drugs in Minas Gerais State, Brazil, and the patients' profile, as well as to analyze the factors associated with individual average monthly costs. Spending on medication for chronic renal failure (R$ 41.6 million, or U$25 million) represents a significant portion of total spending on outpatient procedures in the National health System (9.6%). Most patients are young adult males with arterial hypertension as the main cause of chronic renal failure. Multivariate analysis showed a trend towards lower spending on elderly patients, those with diabetes as the main underlying disease, those using iron hydroxide, and in municipalities with a lower human development index, or HDI (p < 0.05). Finally, the study indicated the importance of management tools that allow monitoring the trajectory of individual patients in the health system and support appropriate health policymaking.
    Cadernos de saúde pública / Ministério da Saúde, Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública 02/2011; 27(2):357-68. · 0.83 Impact Factor
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    ABSTRACT: Objective To describe the expenses of the Ministry of Health of Brazil with users of High-Cost Drug Program that began treatment between 2000–2004, according to their demographic and clinical characteristics.
    Value in Health 01/2011; 14(5). · 2.19 Impact Factor
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    ABSTRACT: To describe the clinical and epidemiological profile of patients under renal replacement therapies, identifying risk factors for death. This is a non-concurrent cohort study of data for 90,356 patients in the National Renal Replacement Therapies Database. A deterministic-probabilistic linkage was performed using the Authorization System for High Complexity/Cost Procedures and the Mortality Information System databases. All patients who started dialysis between 1/1/2000 and 12/31/2004 were included and followed until death or the end of 2004. Age, sex, region of residence, primary renal disease and causes of death were analyzed. A proportional hazards model was used to identify factors associated with risk of death. The prevalence of patients under renal replacement therapies increased an average of 5.5%, while incidence remained stable during the period. Hemodialysis was the predominant initial modality (89%). The patients were majority male with mean age 53 years, residents of the Southeast region and presented unknown causes as the main cause of chronic renal disease, followed by hypertension, diabetes and glomerulonephritis. Of these patients, 42% progressed to death and 7% underwent kidney transplantation. The patients on peritoneal dialysis were older and had higher prevalence of diabetes. The death rate varied from 7% among transplanted patients to 45% among non-transplanted patients. In the final Cox proportional hazards model, the risk of mortality was associated with increasing age, female sex, having diabetes, living in the North and Northeast region, peritoneal dialysis as a first modality and not having renal transplantation. There was an increased prevalence of patients on renal therapy in Brazil. Increased risk of death was associated with advanced age, diabetes, the female sex, residents of the North and Northeast region and lack of renal transplant.
    Revista de saude publica 08/2010; 44(4):639-49. · 1.01 Impact Factor
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    ABSTRACT: The aim of this study was to compare total outpatient expenditures on hemodialysis and peritoneal dialysis from 2000 to 2004 in patients that began dialysis in 2000 under the Unified National Health System (SUS). A historical cohort was developed, consisting of patients that began dialysis in 2000, identified by probabilistic matching in the database of Authorizations for High-Complexity/High-Cost Procedures (APAC). A multiple linear regression model was used, including individual and clinical attributes and health services supply variables. The cohort included 10,899 patients, 88.5% of whom began hemodialysis and 11.5% peritoneal dialysis. The dialysis modality explains 12% of the variance in expenditures, and patients in peritoneal dialysis showed 20% higher mean annual expenditure. The differences in expenditures are explained according to the State of Brazil and health services supply level. Individual risk variables did not alter the model's explanatory power, while age and diabetes mellitus were significant. The study showed the importance of the National Health System's payment mechanism for explaining differences in expenditures on dialysis treatment in Brazil.
    Cadernos de saúde pública / Ministério da Saúde, Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública 08/2010; 26(8):1627-41. · 0.83 Impact Factor
  • Cadernos De Saude Publica - CAD SAUDE PUBLICA. 01/2010; 26(1).
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    ABSTRACT: In Brazil, the Unified National Health System (SUS) is responsible for the majority of kidney transplants. To maintain these interventions, the guidelines recommend the use of cyclosporine or tacrolimus, associated with corticosteroids and azathioprine or mycophenolate. Taking the perspective of the National Health System, an economic analysis was performed on the outpatient and hospital resources and medicines used by patient and therapeutic group. A cohort was constructed from 2000 to 2004, with 5,174 kidney transplant patients in use of cyclosporine or tacrolimus, identified by probabilistic record linkage from the National Health System. The cohort included 4,015 patients in use of cyclosporine and 1,159 using tacrolimus. The majority were males, age < 38 years, with nephritis, cardiovascular diseases, and indeterminate causes as the most frequent primary diagnoses. After 48 months of follow-up, the expenditures were higher for kidney transplants in hospitals in the Northeast, cadaver donors, patients in dialysis > 24 months before the transplant, and in the tacrolimus group. Total hospital and outpatient costs and expenditure on medication were higher in patients on tacrolimus as compared to the cyclosporine group.
    Cadernos de saúde pública / Ministério da Saúde, Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública 01/2010; 26(1):163-74. · 0.83 Impact Factor
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    ABSTRACT: El Programa de Medicamentos Excepcionales del Ministerio de Salud tiene como objetivo satisfacer la demanda de medicamentos de alto valor unitario, o de aquellos empleados en enfermedades crónicas que impliquen un tratamiento de costo elevado. Con el objetivo de describir el perfil demográfico y epidemiológico de los pacientes incluidos en el programa, se realizó una vinculación probabilística-determinística de datos provenientes de registros del DATASUS (Banco de Datos del Sistema Único de Salud): Autorizaciones de Procedimientos de Alta Complejidad/Alto Costo (Apac/SIA) y Sistema de Información sobre Mortalidad (SIM). La cohorte formada a partir de la vinculación de las bases de datos identificó a 611.419 individuos que comenzaron el tratamiento en el período 2000-2004. Los análisis se han separado por sexo, región de residencia, diagnóstico y medicamentos más utilizados. La construcción de esta cohorte histórica permitió la descripción de las características demográficas, epidemiológicas y de utilización de medicamentos de los usuarios del programa. Además, el banco de datos generado hace posible la realización de una serie de análisis específicos para determinación de enfermedades, que pueden contribuir a evaluaciones de eficacia y eficiencia de las alternativas terapéuticas incluidas en los protocolos clínicos, con el objetivo de proporcionar subsidios a quienes toman decisiones con respecto a la planificación de las acciones y la oferta de medicamentos de alto costo por parte del SUS.
    Revista Brasileira de Estudos de População 12/2009; 26(2):263-282.
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    Cadernos De Saude Publica - CAD SAUDE PUBLICA. 01/2008; 24(8).
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    Revista Brasileira de Estudos de População 06/2007; 24(1).
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    ABSTRACT: This article presents a diagnosis of the health economics (HE) in Brazil, based on a survey of HE research groups currently registered in the National Council for Scientific and Technological Development (CNPq), as well as an inventory of the Brazilian scientific production in HE, published between January 1999 and June 2004, available in the Bireme Virtual Health Library (Paho/WHO). It describes the data considering geographic regions, types of institution and topics of research. Of the research groups with works related to HE subject matters, 48 have very diversified activities, concentrated in the Southeastern region of the country. Only 14% (376) of the 2.617 publications that had been evaluated were related to HE. Most of the studies were published in 2002 and their main topics were management, financing, allocative efficiency and equity in the distribution of health resources. The diagnosis allows the identification of important aspects that help understand the development of the HE field in Brazil between 1999 and 2004.
    Revista de Administração Pública 04/2007; 41(2):211-235.
  • Augusto Afonso. Guerra Junior, Francisco de Assis ths Acurcio
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    ABSTRACT: O objetivo foi avaliar a disponibilidade e acessibilidade economica de medicamentos essenciais (ME) para populacoes com baixo indice de desenvolvimento humano. Foi realizado um inquerito com 109 instituicoes de saude publicas, privadas e filantropicas localizadas em 19 municipios de Minas Gerais. O estudo, baseado no metodo de estimativa rapida, entrevistou gestores publicos, profissionais de saude e pacientes, alem de coletar dados de fontes secundarias (...).Constatou-se baixa disponibilidade de ME's nos: alomoxarifados municipais (52 por cento); Unidades publicas de saude (UPS) (46,9 por cento), unidades ambulatoriais filantropicas e privadas (41 por cento e 38,1 por cento). Nas farmacias privadas a disponibilidade foi maior (81,2 por cento). Os custos de aquisicao de ME's variaram no setor publico (...). Em media, os produtos custaram apenas 2,2 por cento a mais que os precos internacionais. Mas custaram 22,3 por cento a mais que precos do Programa Farmacia Basica. Nas farmacias privadas as marcas com menor preco estavam em medias 31,6 por cento abaixo do preco tabelado e as de maior preco estavam 25,1 por cento acima. Perfil prescricoes, o numero medio de medicamentos por prescricao foi de 1,7. A maioria dos medicamentos (69,7 por cento) nao estava disponivel nas UPS. Dos produtos precritos, 23,4 nao pertenciam a RENAME. A dipirona foi a droga mais precrita (9,3 por cento do total e 24, 6 por cento no grupo criancas). Para o paciente simulado em farmacias privadas, a proporcao de MF's sugeridos foi de 63, 2 por cento. O paracetamol foi o analgesico mais sugerido. O custo medio dos produtos por pacientes foi R$16,56. Nao existiam RME disponiveis nas farmacias privadas e a principal fonte de informacao era dicionario de especialildades farmaceuticas (DEF; 95, 2 por cento). Nas UPS e Secretarias Municipais de Saude (SMS) nao se observou o uso efetivo de RME's , apesar de 50 por cento das SMS e de 47,4 por cento das UPS posuirem listas. Conclui-se que o setor publico nao adotou o conceito de essencialidade, havendo baixa disponibilidade e descontinuidade na oferta de ME's, alem da prescricao de marcas de referencias no SUS. A disponibilidade de ME's foi maior nas farmacias privadas, verificou-se que marcas de referencia se encontravam com valor superior ao tabelado, comprometendo a acessibilidade economica. Os resultados apontam a necessidade da adocao de estrategias para divulgar e implementar o conceito de essencialidade no pais. (AU). Mestre -- Universidade Federal de Minas Gerais. Faculdade de Farmacia, Belo Horizonte, 2002.
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