Avaliação económica em transplantação renal : abordagem estratégica do processo de doação e análise de custo-utilidade do programa de transplantação renal versus hemodiálise

SUMÁRIO - O desafio atual da Saúde Pública é assegurar a sustentabilidade financeira do sistema de saúde. Em ambiente de recursos escassos, as análises económicas aplicadas à prestação dos cuidados de saúde são um contributo para a tomada de decisão que visa a maximização do bem-estar social sujeita a restrição orçamental. Portugal é um país com 10,6 milhões de habitantes (2011) com uma incidência e prevalência elevadas de doença renal crónica estadio 5 (DRC5), respetivamente, 234 doentes por milhão de habitantes (pmh) e 1.600 doentes/pmh. O crescimento de doenças associadas às causas de DRC, nomeadamente, diabetes Mellitus e hipertensão arterial, antecipam uma tendência para o aumento do número de doentes. Em 2011, dos 17.553 doentes em tratamento substitutivo renal, 59% encontrava-se em programa de hemodiálise (Hd) em centros de diálise extra-hospitalares, 37% viviam com um enxerto renal funcionante e 4% estavam em diálise peritoneal (SPN, 2011). A lista ativa para transplante (Tx) renal registava 2.500 doentes (SPN 2009). O Tx renal é a melhor modalidade terapêutica pela melhoria da sobrevida, qualidade de vida e relação custo-efetividade, mas a elegibilidade para Tx e a oferta de órgãos condicionam esta opção. Esta investigação desenvolveu-se em duas vertentes: i) determinar o rácio custo-utilidade incremental do Tx renal comparado com a Hd; ii) avaliar a capacidade máxima de dadores de cadáver em Portugal, as características e as causas de morte dos dadores potenciais a nível nacional, por hospital e por Gabinete Coordenador de Colheita e Transplantação (GCCT), e analisar o desempenho da rede de colheita de órgãos para Tx. Realizou-se um estudo observacional/não interventivo, prospetivo e analítico que incidiu sobre uma coorte de doentes em Hd que foi submetida a Tx renal. O tempo de seguimento mínimo foi de um ano e máximo de três anos. No início do estudo, colheram-se dados sociodemográficos e clínicos em 386 doentes em Hd, elegíveis para Tx renal. A qualidade de vida relacionada com a saúde (QVRS) foi avaliada nos doentes em Hd (tempo 0) e nos transplantados, aos três, seis, 12 meses, e depois, anualmente. Incluíram-se os doentes que por falência do enxerto renal transitaram para Hd. Na sua medição, utilizou-se um instrumento baseado em preferências da população, o EuroQol-5D, que permite o posterior cálculo dos QALY. Num grupo de 82 doentes, a QVRS em Hd foi avaliada em dois tempos de resposta o que permitiu a análise da sua evolução. Realizou-se uma análise custo-utilidade do Tx renal comparado com a Hd na perspetiva da sociedade. Identificaram-se os custos diretos, médicos e não médicos, e as alterações de produtividade em Hd e Tx renal. Incluíram-se os custos da colheita de órgãos, seleção dos candidatos a Tx renal e follow-up dos dadores vivos. Cada doente transplantado foi utilizado como controle de si próprio em diálise. Avaliou-se o custo médio anual em programa de Hd crónica relativo ao ano anterior à Tx renal. Os custos do Tx foram avaliados prospetivamente. Considerou-se como horizonte temporal o ciclo de vida nas duas modalidades. Usaram-se taxas de atualização de 0%, 3% e 5% na atualização dos custos e QALY e efetuaram-se análises de sensibilidade one way. Entre 2008 e 2010, 65 doentes foram submetidos a Tx renal. Registaram-se, prospetivamente, os resultados em saúde incluíndo os internamentos e os efeitos adversos da imunossupressão, e o consumo dos recursos em saúde. Utilizaram-se modelos de medidas repetidas na avaliação da evolução da QVRS e modelos de regressão múltipla na análise da associação da QVRS e dos custos do transplante com as características basais dos doentes e os eventos clínicos. Comparativamente à Hd, observou-se melhoria da utilidade ao 3º mês de Tx e a qualidade de vida aferida pela escala EQ-VAS melhorou em todos os tempos de observação após o Tx renal. O custo médio da Hd foi de 32.567,57€, considerado uniforme ao longo do tempo. O custo médio do Tx renal foi de 60.210,09€ no 1º ano e 12.956,77€ nos anos seguintes. O rácio custo-utilidade do Tx renal vs Hd crónica foi de 2.004,75€/QALY. A partir de uma sobrevivência do enxerto de dois anos e cinco meses, o Tx associou-se a poupança dos custos. Utilizaram-se os dados nacionais dos Grupos de Diagnóstico Homogéneos e realizou-se um estudo retrospectivo que abrangeu as mortes ocorridas em 34 hospitais com colheita de órgãos, em 2006. Considerou-se como dador potencial o indivíduo com idade entre 1-70 anos cuja morte ocorrera a nível hospitalar, e que apresentasse critérios de adequação à doação de rim. Analisou-se a associação dos dadores potenciais com características populacionais e hospitalares. O desempenho das organizações de colheita de órgãos foi avaliado pela taxa de conversão (rácio entre os dadores potenciais e efetivos) e pelo número de dadores potenciais por milhão de habitantes a nível nacional, regional e por Gabinete Coordenador de Colheita e Transplantação (GCCT). Identificaram-se 3.838 dadores potenciais dos quais 608 apresentaram códigos da Classificação Internacional de Doenças, 9.ª Revisão, Modificações Clínicas (CID- 9-MC) que, com maior frequência, evoluem para a morte cerebral. O modelo logit para dados agrupados identificou a idade, o rácio da lotação em Unidades de Cuidados Intensivos e lotação de agudos, existência de GCCT e de Unidade de Transplantação, e mortalidade por acidente de trabalho como fatores preditivos da conversão dum dador potencial em efetivo e através das estimativas do modelo logit quantificou-se a probabilidade dessa conversão. A doação de órgãos deve ser assumida como uma prioridade e as autoridades em saúde devem assegurar o financiamento dos hospitais com programas de doação, evitando o desperdício de órgãos para transplantação, enquanto um bem público e escasso. A colheita de órgãos deve ser considerada uma opção estratégica da atividade hospitalar orientada para a organização e planeamento de serviços que maximizem a conversão de dadores potenciais em efetivos incluindo esse critério como medida de qualidade e efetividade do desempenho hospitalar. Os resultados deste estudo demonstram que: 1) o Tx renal proporciona ganhos em saúde, aumento da sobrevida e qualidade de vida, e poupança de custos; 2) em Portugal, a taxa máxima de eficácia da conversão dos dadores cadavéricos em dadores potenciais está longe de ser atingida. O investimento na rede de colheita de órgãos para Tx é essencial para assegurar a sustentabilidade financeira e promover a qualidade, eficiência e equidade dos cuidados em saúde prestados na DRC5.

Basel III new capital requirements, impacts and bank behavior

For some years, researchers could not find a clear effect of capital adequacy on the risk profile of banks, as shareholders could increase the riskiness of the assets (qualitative effect), crowding-out the effect of reduced leverage (volume effect). Some shareholders might have the will to increase the riskiness of the assets, but they may lack the power to do so. Considering only ”powerful” shareholders, definitive conclusions were drawn but with constant ownership profile. In this paper I investigate whether there is a significant change in the type of shareholders in response to regulatory capital shocks and, if so, will the banking system be in the hands of more “desired” shareholders. I find that ownership profile responds to a regulatory shock, changing the risk appetite of the ruling power at the bank. I find more banks and the government in the ownership of undercapitalised banks and much less institutional shareholders and free float. I claim that these new shareholders may not the desired ones, given the objective of the regulatory change, as they are associated with a preference for more leverage. One possible explanation for this crowding-out effect is that regulators are trying to contain idiosyncratic risk (more linked to the riskiness of the assets) with a rule that contains systematic risk (capital adequacy). This has a distorting effect on ownership. Another insight can be drawn from the tests: supervisors should be aware of significant ownership movements that cause the crowding-out.

The late adopter scale: A measure of late adopters of technological innovations

Diffusion of Innovation is a topic of interest for researchers and practitioners. Although substantial research is conducted on user categories, researchers often focus on the first half of the curve, ignoring the late adopters. We conduct two studies to measure the attributes of late adopters. In our first study of mobile phone users, we develop the Late-Adopter Scale. We then test it on a sample of laptop users. This scale is multi-dimensional, presents nomological and discriminant validity and has three dimensions: 1) rate of adoption, 2) resistance to innovation, and 3) skepticism. Findings reveal that all three Late Adopter Scale dimensions are significantly associated with low price preference. Moreover, in both samples skepticism is associated with high preference for simple products, lower leading edge status, and lower product involvement. Discussion focuses on implications of this new scale to theory and practice of new product development and diffusion of innovation.

Learning domain-specific sentiment lexicons with applications to recommender systems

Search is now going beyond looking for factual information, and people wish to search for the opinions of others to help them in their own decision-making. Sentiment expressions or opinion expressions are used by users to express their opinion and embody important pieces of information, particularly in online commerce. The main problem that the present dissertation addresses is how to model text to find meaningful words that express a sentiment. In this context, I investigate the viability of automatically generating a sentiment lexicon for opinion retrieval and sentiment classification applications. For this research objective we propose to capture sentiment words that are derived from online users’ reviews. In this approach, we tackle a major challenge in sentiment analysis which is the detection of words that express subjective preference and domain-specific sentiment words such as jargon. To this aim we present a fully generative method that automatically learns a domain-specific lexicon and is fully independent of external sources. Sentiment lexicons can be applied in a broad set of applications, however popular recommendation algorithms have somehow been disconnected from sentiment analysis. Therefore, we present a study that explores the viability of applying sentiment analysis techniques to infer ratings in a recommendation algorithm. Furthermore, entities’ reputation is intrinsically associated with sentiment words that have a positive or negative relation with those entities. Hence, is provided a study that observes the viability of using a domain-specific lexicon to compute entities reputation. Finally, a recommendation system algorithm is improved with the use of sentiment-based ratings and entities reputation.

Exploring the consumer decision journey and online shoping experience through an emotional prespective

Traditional consumer decision-making models have long used quantitative research to address a link between emotional and rational behavior. However, little qualitative research has been conducted in the area of online shopping as an end-to-end experience. This study aims to provide a detailed phenomenological account of consumers’ online shopping experience and extend Mckinsey & Companys’s consumer decision journey model from an emotional perspective. Six semi-structured interviews and a focus group of nine people are analyzed using Interpretive Phenomenology Analysis and five superordinate themes emerged from the results: emotional experience, empathy and encouragement, in relation to brand preference, emotional encounters in relation to consumer satisfaction and emotional exchange and relationship with a company or brand. A model interrelating these themes is then introduced to visually represent the emotional essence of a large online purchase. This study promises to be applicable as a descriptive, and perhaps, better predictive report for understanding the complex consumer decision-making process as it relates to online consumer behavior. Future research topics are also identified.

Nutritional preferences of wood-feeding termites inhabiting floodplain forests of the Amazon River, Brazil

The alimentary preferences of five species of wood-feeding termites of the genus Nasutitermes that coexist in the inundated forests of the floodplains of the Amazon river várzea for species of fresh wood and for wood in different stages of decomposition was evaluated in laboratory tests. Wood of low density was generally preferred; the decay stages were preferred over fresh wood. The five termite species differ in the amplitude of their choices, indicating a strong differentiation in food choice among them. Differences in feeding preferences may be a niche-separating factor for these five Nasutitermes species of the floodplains.

Levels of leaf Herbivory in Amazonian trees from different stages In forest regeneration

Leaves from 120 canopy trees and 60 understory tree saplings growing in primary and secondary forests near Manaus, Brazil, were collected for determination of standing levels of herbivory (percent leaf area lost). Overall, levels of herbivory on leaves of central Amazonian trees were low. About one quarter of the leaves examined (n = 855) had no damage at all. In most other Neotropical sites studied the mean percentage of herbivory was found to vary between 5.7 and 13.1%, whereas in Manaus it was only 3.1%. The data presented here support the contention that levels of herbivore damage are positively related to soil fertility. No significant difference was found in herbivory levels between canopy trees and understory saplings. Also, there was no difference in damage between leaves from pioneer and late successional trees. Field assays of preference, however, revealed that leaves from pioneer trees are more palatable to leaf-cutting ants (Atta laevigata). This effect was dependent upon leaf age, being observed in mature leaves, but not in young leaves. The greater rate of leaf production in secondary forests may be a factor accounting for the greater abundance of leaf-cutting ants in secondary compared to primary forests.

Geological control of Podocnemis expansa and Podocnemis unifilis nesting areas in Rio Javaés, Bananal Island, Brazil

The distribution of the nests of Podocnemis expansa (Amazon turtle) and Podocnemis unifilis (yellow-spotted side neck turtle) along the point bars of the Javaés River in Bananal Island, demonstrates a clear preference of these chelonians for differentiated geological environments, in respect to the morphology, grain size or height of the nests in relation to the level of the river. The topographical distribution and the differences in the grain size of the sediments that compose the point bars of the river, originated from the multiple sedimentary processes, and make possible the creation and separation of different nesting environments. Each turtle species takes advantage of the place that presents physiographic characteristics appropriate to the hatching success of their eggs. The superposition of the P. expansa and P. unifilis nest placement areas is rare. The P. expansa nests are concentrated on the central portion of the beaches where successive depositional sedimentary events produced sandy banks more than 3.3 m above the river water level. The P. unifilis nests are distributed preferentially in the upstream and downstream portions along the point bars where the sandy deposits rarely surpass 1.5 m at the moment of laying. P. expansa nests located on the beaches of fine to medium sized sand hatch in a mean of 68 days, while those incubated on beaches of medium to coarse sand size take a mean of 54 days to hatch.

Interaction paradigms versus age-related user profiles: an evaluation on content selection

Novel input modalities such as touch, tangibles or gestures try to exploit human's innate skills rather than imposing new learning processes. However, despite the recent boom of different natural interaction paradigms, it hasn't been systematically evaluated how these interfaces influence a user's performance or whether each interface could be more or less appropriate when it comes to: 1) different age groups; and 2) different basic operations, as data selection, insertion or manipulation. This work presents the first step of an exploratory evaluation about whether or not the users' performance is indeed influenced by the different interfaces. The key point is to understand how different interaction paradigms affect specific target-audiences (children, adults and older adults) when dealing with a selection task. 60 participants took part in this study to assess how different interfaces may influence the interaction of specific groups of users with regard to their age. Four input modalities were used to perform a selection task and the methodology was based on usability testing (speed, accuracy and user preference). The study suggests a statistically significant difference between mean selection times for each group of users, and also raises new issues regarding the “old” mouse input versus the “new” input modalities.

Haematophagic behavior in laboratory of Lutzomyia cruzi (Mangabeira) (Diptera: Psychodidae) in relation to three mammalian blood sources in Manaus, Brazil

The sand fly Lutzomyia cruzi is considered as one of vectors of visceral leishmaniasis in Brazil. This work examined optimum feeding age, feeding time, host preference, fecundity rates, and female blood meal volume taken by single females from a closed colony of L. cruzi. Mean feeding time was longer on hamsters, 6.6 minutes, than on humans, 5.7 minutes. 49.1% of the 48h-old flies fed on humans and 43.3% of 72h-old flies fed on hamsters. Of a total of 120 females, 61% fed on humans and 25% fed on hamsters. Total fecundity was significantly higher in females fed on hamster than on human or opossum. Laboratory-reared L. cruzi females fed earlier, more promptly, and preferably on humans than on hamsters when offered these blood-meal sources simultaneously. The blood-meal volume is higher in females fed on hamsters than other hosts (human and opossum).

User expectations for media sharing practices in open display networks

Open Display Networks have the potential to allow many content creators to publish their media to an open-ended set of screen displays. However, this raises the issue of how to match that content to the right displays. In this study, we aim to understand how the perceived utility of particular media sharing scenarios is affected by three independent variables, more specifically: (a) the locativeness of the content being shared; (b) how personal that content is and (c) the scope in which it is being shared. To assess these effects, we composed a set of 24 media sharing scenarios embedded with different treatments of our three independent variables. We then asked 100 participants to express their perception of the relevance of those scenarios. The results suggest a clear preference for scenarios where content is both local and directly related to the person that is publishing it. This is in stark contrast to the types of content that are commonly found in public displays, and confirms the opportunity that open displays networks may represent a new media for self-expression. This novel understanding may inform the design of new publication paradigms that will enable people to share media across the display networks.

Use of the flooded forest by fish assemblages in lakes of the National Park of Anavilhanas (Amazonas, Brazil)

We evaluated diversity and distribution of fish species in two habitats: flooded forest and open water of lakes of Rio Negro. Each of four lakes within the Anavilhanas Archipelago was sampled three times from 2009-2010. Species diversity generally was higher in flooded forests and at night, according to correspondence analysis. Predators were most active at night, but showed no preference between the flooded forest and open water habitats. Omnivores, filter feeders, and detritivores were most active during the day.

Predicting the distribution of forest tree species using topographic variables and vegetation index in eastern Acre, Brazil

Species distribution modeling has relevant implications for the studies of biodiversity, decision making about conservation and knowledge about ecological requirements of the species. The aim of this study was to evaluate if the use of forest inventories can improve the estimation of occurrence probability, identify the limits of the potential distribution and habitat preference of a group of timber tree species. The environmental predictor variables were: elevation, slope, aspect, normalized difference vegetation index (NDVI) and height above the nearest drainage (HAND). To estimate the distribution of species we used the maximum entropy method (Maxent). In comparison with a random distribution, using topographic variables and vegetation index as features, the Maxent method predicted with an average accuracy of 86% the geographical distribution of studied species. The altitude and NDVI were the most important variables. There were limitations to the interpolation of the models for non-sampled locations and that are outside of the elevation gradient associated with the occurrence data in approximately 7% of the basin area. Ceiba pentandra (samaúma), Castilla ulei (caucho) and Hura crepitans (assacu) is more likely to occur in nearby water course areas. Clarisia racemosa (guariúba), Amburana acreana (cerejeira), Aspidosperma macrocarpon (pereiro), Apuleia leiocarpa (cumaru cetim), Aspidosperma parvifolium (amarelão) and Astronium lecointei (aroeira) can also occur in upland forest and well drained soils. This modeling approach has potential for application on other tropical species still less studied, especially those that are under pressure from logging.

Spawning habitat selection by Octopus vulgaris: new insights for a more effective management of this resource

The selection of spawning habitat of a population of Octopus vulgaris that is subject to a small-scale exploitation was studied in the Cíes Islands within the National Park of the Atlantic Islands of Galicia (NW Spain). The technique used was visual censuses by scuba diving. We conducted 93 visual censuses from April 2012 to April 2014. The total swept area was 123.69 ha. Habitat features (season, depth, zone, bottom temperature, swept area, bottom substrate type, and creels fishing impact) were evaluated as predictors of the presence/absence of spawning dens using GAM models. O. vulgaris has a noteworthy preference for spawning in areas with hard bottom substrate and moderate depth (approximately 20 m). The higher density of spawning dens (1.08ha−1) was found in a surveyed area of 50.14ha located in the northeastern part of the northern Cíes Island. We propose to protect the area comprised from Punta Escodelo to Punta Ferreiro between 5 and 30 m depth. This area has a surface of 158 ha equivalent to 5.98% of the total marine area of the Cíes islands. The strengths and weaknesses of a management strategy based on the protection of the species’ spawning habitat are discussed.

A relação entre jornalistas e leitores no online: análise do feedback do público durante a experiência de estágio no P3

Relatório de estágio de mestrado em Ciências da Comunicação (área de especialização em Informação e Jornalismo)