Os custos das fracturas de etiologia osteopor��tica em mulheres : institucionaliza����o na Rede Nacional de Cuidados Continuados (RNCCI) e lares de 3�� idade

RESUMO - Contexto: A osteoporose �� uma doen��a sist��mica associada �� diminui����o da resist��ncia ��ssea que condiciona o aparecimento de fracturas por traumatismos de baixa energia as quais reduzem em muitos casos a esperan��a e a qualidade de vida, implicando um elevado n��mero de horas de dedica����o dos cuidadores e conduzindo, em muitos casos, �� necessidade de institucionaliza����o dos doentes. Em Portugal, ocorrem cerca de 40.000 fracturas anualmente, das quais 8.500 do f��mur proximal, que se estima consumirem mais de 50 milh��es de euros s�� em cuidados hospitalares1. Objectivo: Avaliar o impacto econ��mico da institucionaliza����o na Rede Nacional de Cuidados Continuados Integrados e Lares da 3�� idade por fractura de etiologia osteopor��tica em mulheres no ano 2009, em Portugal. M��todos: O estudo come��a por analisar sucintamente os aspectos cl��nicos, sociais e epidemiol��gicos da osteoporose, focando a perda de autonomia e qualidade de vida dos doentes v��timas deste epis��dio e a subsequente necessidade de institucionaliza����o. Descrevem-se os custos associados �� institucionaliza����o na RNCCI, em Portugal, ano 2009, utilizando como fonte principal a base de dados da institui����o ���Gestcare CCI���, complementada com dados da literatura. Apuram-se os custos totais associados ao encaminhamento dos doentes para Lares de 3�� Idade em Portugal no ano 2009, utilizando-se informa����o proveniente de um painel de Delphi modificado e dados da literatura. A valoriza����o dos recursos tem por base os pre��os em vigor no territ��rio nacional, expressos nos decretos-lei devidamente referenciados. Resultados: No ano 2009 em Portugal foram empregues cerca de 2,5 milh��es de euros no internamento das mulheres na RNCCI, na perspectiva da sociedade, sendo cerca de 2,2 milh��es atribu��veis �� osteoporose (90%). Cerca de 91% dos custos totais s��o alocados �� fractura osteopor��tica da anca (2 milh��es ���). Para a fractura vertebral, ��mero e punho os custos foram mais baixos - 7,1%, 1,3% e 1% dos custos totais da osteoporose, respectivamente. Nos Lares de 3�� idade, estimou-se a admiss��o de aproximadamente 14.372 doentes com fractura osteopor��tica em diferentes localiza����es, em 2009, Portugal, com um custo que oscilou entre os 19 e os 21,6 milh��es de euros. A fractura osteopor��tica da anca foi a mais incidente e a que representou custos mais elevados para a Seguran��a Social ��� entre 17,5 e 19,7 milh��es de euros. Considerando como refer��ncia os 52 milh��es de euros gastos em 2006 no tratamento hospitalar da fractura da anca (DGS, 2006), o encaminhamento das mulheres para a RNCCI e Lares da 3�� Idade corresponde a 42% do bolo total. Assim, os resultados nacionais enquadram-se no que se encontra descrito na literatura internacional - os custos atribu��veis �� hospitaliza����o oscilaram entre 17%50 e 63%29 da despesa total da doen��a e das institucionaliza����es entre os 16%58 e os 59%51. Conclus��es: Em Portugal o impacto econ��mico da institucionaliza����o por fractura osteopor��tica, sobretudo por fractura da anca, n��o �� desprez��vel e mostra que existiriam poupan��as significativas se fosse poss��vel reduzir a preval��ncia da doen��a em Portugal. Face ��s altera����es demogr��ficas associadas ao envelhecimento da popula����o, �� expect��vel que a incid��ncia e custos com o tratamento das fracturas do colo do f��mur, mais associadas �� osteoporose, venham a subir nos pr��ximos anos, pelo que o combate �� doen��a deve ser considerada uma prioridade nacional. A decis��o pela op����o por determinados programas de preven����o da doen��a ou da comparticipa����o ou n��o de determinada terap��utica necessita contudo de ser complementada com a medi����o da dimens��o dos benef��cios terap��uticos. --- ABSTRACT - Background: Osteoporosis is a systemic disease associated with the loss off the bone strength and it is one of the major causes of low energy fractures, which in many cases reduce life hope and quality. This happens because it has associated extensive treatments and it usually carries loss of independence, implying many hours of caregivers dedication and leading, in many cases, to the institutionalization of the patients. In Portugal, about 40,000 fractures occur annually, which 8,500 are proximal femur, and that are estimated to consume over 50 million euros only in hospital care. Objective: Evaluate the economic impact of institutionalization on the Integrated Continued Care National Network (RNCCI) and Care Homes associated to osteoporotic fractures in women, in the year 2009 in Portugal. Methods: The study begins by reviewing briefly the clinical, social, and epidemiological studies of osteoporosis and osteoporotic fractures, focusing on the patient autonomy loss and life quality. The total and average costs per episode associated with the institutionalization in RNCCI are described, in Portugal, year 2009, using as main data source the application "Gestcare CCI", complemented with literature data. The total costs associated with the patients referral for the Care Homes in Portugal in 2009 is also calculated, using information from a modified Delphi panel and some literature data. The resources valuation is based on prices prevailing in Portugal. Results: In 2009, women relocation in RNCCI consumed approximately 2.5 million euros, which 2.2 million are attributable to osteoporosis (90%). About 91% of the total costs are allocated to osteoporotic hip fracture (��� 2 million). For vertebral, humerus, and wrist fracture, the associated costs were lower, 7.1%, 1.3%, and 1% of total costs of osteoporosis treatment, respectively. In Care Homes, an intake of approximately 14 372 patients with osteoporotic fracture was estimated, at a cost that is between 19 and 21.6 million euros. The osteoporotic hip fracture was the most frequent and represented higher costs for Social Security - between 17.5 and 19.7 million euros. Taking as reference the 52 million spent in 2006 with hospital treatment of hip fracture (DGS, 2006), referring women to RNCCI and Care Homes represents 42% of the total costs. The results are in accordance with the international literature - costs attributable to hospitalization ranged between 17% and 63% of total expenditure of illness and institutionalization between 16% and 59%. Conclusions: In Portugal, the economic impact of institutionalization for osteoporotic fracture, particularly for hip fracture, is not negligible. It was shown that there would be significant savings if it were possible to reduce the prevalence of the disease in Portugal. Femoral fractures were the second most frequent diagnosis in RNCCI in 2008 and 2009 (16% of all episodes recorded). The execution of RNCCI in 2008 was 75 million euros, and 2.7% consumed by hip fracture and 0.3% by wrist, humerus, and spine fractures. The average cost per episode in 2009, from the perspective of society, for hip fracture, vertebral, humerus, and wrist (or non-osteoporotic) was ��� 5,195, ��� 5,160, ��� 5,030, and ��� 4,854 respectively. Thus, considering an average cost per episode in RNCCI from January to March of 3230���, the expense related to the treatment of these patients in RNCCI in 2009 was higher. For the Care Homes, an intake of approximately 14 372 patients with osteoporotic fracture in 2009 was estimated, at a cost to Social Security that ranged from 19 to 21.6 million ���. The osteoporotic hip fracture was the most frequent and it was shown to absorve higher resources from Social Security - between 17.5 and 19.7 million ���. This was followed by the analysis of vertebral and humerus fracture and the results showed that these fractures have a low incidence and low proportion of institutionalization, with a significantly lower cost - only about 4.7% and 3.3% of total expenditure, respectively. With demographic changes associated to ageing, it is expected that the incidence and treatment cost of the femoral neck fractures, more commonly associated with osteoporosis, will climb in coming years, so the fight against the disease should be considered a national priority. The decision to choose a certain disease prevention program or to reimburse a certain drug not should only account about the costs, but also the benefits of it. In fact, the size and impact of this problem, makes it necessary to focus all interventions in the prevention of these episodes either by using an appropriate therapy, either through real programs for disease prevention. Once the problem is installed, we must measure the health gains associated with the patient institutionalization by conducting additional research.

As fracturas do tempo delfico na poesia de Sophia de Mello Breyner Andresen

Para um poeta fenomenologista, o espa��o deve ser todo o lugar vis��vel e de alguma forma alcan����vel, tal como o tempo deve ser todas as dura����es que possam fazer parte da nossa experi��ncia de sujeitos. Caso contr��rio, mergulhamos numa dimens��o esp��cio-temporal puramente idealista. O imagin��rio phant��stico', que trabalha com estes ideais - por oposi����o ao imagin��rio real, que diz respeito ��s vis��es fenomenologistas -, ��, em geral, o respons��vel pelas vis��es po��ticas do espa��o e do tempo. Poucos poetas resistem a n��o falar destas duas categorias. E poucos o fazem com acerto filos��fico. Por julgarmos tudo saber sobre o espa��o e o tempo, parece f��cil poetar sobre os efeitos que exercem sobre sujeitos quase sempre deles sofredores. Sophia tem sido apontada como um modelo de poeta que controla como poucos as met��foras poss��veis do espa��o e do tempo. Iremos refutar este pr��-conceito.

Prevenci��n y control de alcohol y drogas en la gesti��n de riesgos laborales

Memoria presentada para optar al grado de Doctor en Higiene, Salud y Seguridade en el Trabajo