Objective: To determine, based on international guidelines for asthma management, the appropriateness of the treatment that the Unified Health Care System provides to patients with asthma. Methods: This was a cross-sectional study involving patients suspected of having asthma and referred to the Pulmonology Clinic of the Federal University of Minas Gerais Hospital das Clínicas, Brazil, between November of 2006 and October of 2007. Results: A total of 102 patients were included, and 70 were diagnosed with asthma. The previous treatment was consistent with the guidelines in 18.6% of the patients; 50.0% of the patients had previously been submitted to spirometry, and 34.3% had previously been submitted to PEF. The most frequently prescribed medication was short-acting β2 agonists (90.3%). Conclusions: The results show that the majority of non-specialized physicians working within the public health care system do not manage the treatment of patients with asthma in accordance with the guidelines. This situation calls for continuing medical education programs that prioritize primary care.

Keywords: Asthma; Guideline adherence; Therapeutics; Public health.

Objective: To analyze the number of hospitalizations, the length of hospital stay, and mortality due to asthma, as well as the costs to the Unified Health Care System in Brazil between 2008 and 2021. Methods: This was a cross-sectional epidemiological study using data from the Information Technology Department of the Brazilian Unified Health Care System. Proportional hospitalization and death rates were estimated per 100,000 population by age, microregion, and year. Results: The number of hospitalizations and deaths due to asthma decreased from 2008 to 2021 (205,392 vs. 55,009 and 822 vs. 327, respectively). In addition, a between-sex difference was observed in asthma-related hospitalizations in 2008, and more men were hospitalized in 2021 (51.8%). Asthma mortality rates were similar for both sexes (50.0% each) in 2008, and a slight increase was observed in women's deaths in 2021 (52.9%). Even so, approximately one death/day and more than 55,000 hospitalizations were observed yearly, with a mean length of hospital stay of three days. Additionally, the Southeast region allocated more financial resources to asthma-related hospitalizations. Conclusions: Our results showed that the number of deaths and hospitalizations due to asthma substantially declined during the study period.

Keywords: Asthma/mortality; Asthma/epidemiology; Hospitalization; National health programs.

Objective: Lung cancer is an important health problem due to its high incidence and mortality. The treatment of metastatic disease improved after the molecular pathways of cancer came to be known. However, targeted therapy is unavailable to many patients treated within the Brazilian Sistema Único de Saúde (SUS, Unified Health Care System). Our objective was to assess the cost-effectiveness of erlotinib, gefitinib, and afatinib versus that of chemotherapy for the treatment of non-small cell lung cancer in the context of the SUS. Methods: Different analytical models were developed based on data in the literature. The outcomes were presented in quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) per QALY gained. All costs related to treatment and supportive therapies were included in the models. Results: In one model, data from retrospective studies showed 2.01 life-years saved and a mean QALY gain of 1.169. The ICER per QALY gained ranged from R$48,451.29 (for gefitinib) to R$85,559.22 (for erlotinib). In another model, data from a meta-analysis showed −0.01 life-years saved and a mean QALY gain of 0.178. The ICER per QALY gained ranged from R$27,028.30 (for gefitinib) to R$75,203.26 (for erlotinib). Conclusions: There is no ideal analytical model for the SUS. However, targeted therapy with EGFR-tyrosine kinase inhibitors has been shown to be cost-effective in various scenarios. The adoption of drug price discounts will improve the cost-effectiveness of treatment.

Keywords: Health policy; Molecular targeted therapy; Economics, pharmaceutical; Brazil.

We estimated the costs of a molecular test for Mycobacterium tuberculosis and resistance to rifampin (Xpert MTB/RIF) and of smear microscopy, within the Brazilian Sistema Único de Saúde (SUS, Unified Health Care System). In SUS laboratories in the cities of Rio de Janeiro and Manaus, we performed activity-based costing and micro-costing. The mean unit costs for Xpert MTB/RIF and smear microscopy were R$35.57 and R$14.16, respectively. The major cost drivers for Xpert MTB/RIF and smear microscopy were consumables/reagents and staff, respectively. These results might facilitate future cost-effectiveness studies and inform the decision-making process regarding the expansion of Xpert MTB/RIF use in Brazil

Keywords: Costs and cost analysis; Tuberculosis; Nucleic acid amplification techniques.

Objective: To describe COPD pharmacological treatment patterns in the state of Bahia, Brazil, and to evaluate the extent to which these patterns conform to clinical guidelines for the management of COPD. Methods: This was a cross-sectional study of 441 patients referred from the Public Health Care Network of the state of Bahia to a public referral outpatient clinic of a COPD management program of the Brazilian Unified Health Care System. Individuals with a spirometry-confirmed diagnosis of moderate to very severe COPD were included in the study. Patients were evaluated as to whether they had used any COPD medications in the last seven days. The appropriateness or inappropriateness (undertreatment or overtreatment) of the patient's pharmacological treatment was evaluated by comparing the patient's current treatment with that recommended by national and international guidelines. Results: A total of 383 individuals were included in the analysis. Approximately half of the patients (49.1%) used long-acting bronchodilators. These patients were older and had had the disease longer. Of the sample as a whole, 63.7% and 83.0% did not receive pharmacological treatment in accordance with international and national recommendations, respectively. Inappropriateness due to undertreatment was indentified in more than half of the patients. Conclusions: Long-acting bronchodilators are frequently underused in individuals with moderate to very severe COPD within the Brazilian Unified Health Care System in the state of Bahia. Most patients in our sample were treated inappropriately, and undertreatment predominated. Strategies to improve access to long-acting bronchodilators and the quality of COPD pharmacological management are required.

Keywords: Pulmonary disease, chronic obstructive/therapy; Drug therapy; Clinical protocols

Objective: To quantify the use of health care resources among patients enrolled in the Bahia State Asthma and Allergic Rhinitis Control Program. Methods: As of January of 2006, 1405 patients had enrolled in the program, which is carried out in four referral centers in the city of Salvador. These patients formed the basis of this retrospective/prospective, observational cohort study. The preliminary analysis involved 269 consecutive patients, all above the age of 12 and diagnosed with severe asthma. After being seen by pulmonologists, nurses, pharmacologists and psychologists, the patients received inhaled asthma medications. Based on patient interviews and charts, the year preceding enrollment in the program was compared with the first year enrolled in the program in terms of the following quantifiable parameters: hospital admissions; emergency room visits; courses of oral corticosteroids; and days of school/work missed due to asthma attacks. Results: In this sample of patients with severe asthma, enrollment in the program resulted in significant reductions in the number of emergency room visits and hospital admissions (of 85% and 90%, respectively). There were also reductions in the number of school/work days missed due to asthma attacks and in the number of courses of oral corticosteroids (of 86% and 67%, respectively). Conclusion: A program designed to control severe asthma in referral outpatient clinics and including pharmacological services at no charge can lead to a pronounced reduction in the demand for Unified Health Care System resources.

Keywords: Asthma/therapy; Asthma/prevention  control; Hospitalization; National Health System (BR)

Objective: To analyze the role that low income plays in the development of asthma in children and adolescents. Methods: A case-control study using a questionnaire. Results: A total of 687 participants were studied at a tertiary hospital via the Brazilian Unified Health System. Ages ranged from 5 to 15 years, and 54.7% of the participants were male. Nearly half of the individuals (49.1%) lived in the metropolitan area of the city of Recife, and the remainder lived in the countryside. Most (98.1%) lived in concrete houses or apartments, with a mean of 5.7 rooms and 4.8 occupants per residence. Mean maternal level of education was 6.8 years of schooling. The median monthly per capita income was R$ 103.75 (Brazilian reals). The sample was stratified according to cut-off points related to the national minimum wage (R$ 350.00): <25% of minimum wage = very low income (39% of the sample); <50% of minimum wage = low income (37.3% of the sample); and ≥50% of minimum wage = satisfactory income (23.7% of the sample). There was no association between poverty and development of asthma. Conclusions: Poverty is not protective against asthma in children and adolescents treated via the Brazilian Unified Health System, as we might suppose based on the hygiene hypothesis. However, cohort studies are needed in order to confirm these findings.

Keywords: Asthma; Poverty; National health programs/Brazil; Child; Adolescent; Case-control studies.

Objective: To assess the effect of psychotherapy on levels of anxiety and depression, as well as on quality of life and exercise capacity in patients with chronic obstructive pulmonary disease enrolled in a pulmonary rehabilitation program. Methods: A randomized, controlled, blind clinical trial was conducted involving 49 chronic obstructive pulmonary disease patients. Patients were randomized into three groups: those submitted to the complete pulmonary rehabilitation program, which included psychotherapy and an exercise regimen (group 1); those submitted to the program minus physical exercise (group 2); and those submitted to the program minus psychotherapy (group 3). The three groups underwent a 12-week treatment program. All patients were evaluated at baseline and at completion of the pulmonary rehabilitation program through four instruments: The Beck Anxiety Inventory, Beck Depression Inventory and St. George's Respiratory Questionnaire were applied. The distance walked-weight product was also calculated. Results: Statistically significant absolute improvements in exercise capacity were found for groups 1 and 2, although not for group 3 (p = 0.007, p = 0.008 and p = 0.06, respectively). In groups 1 and 2, levels of anxiety and depressions were also significantly reduced (group 1: p = 0.0000 and p < 0.0003; group 2: p = 0.0001 and p = 0.0014), and quality of life was significantly improved (p = 0.0007 and p = 0.002, respectively). Anxiety levels were also reduced in group 3 (p = 0.03), although levels of depression were not, and quality of life was unaffected. Conclusion: Psychotherapy sessions provided as part of a pulmonary rehabilitation program assist patients with chronic obstructive pulmonary disease in coping with disease-related limitations by reducing behavioral symptoms, especially depression, thereby influencing exercise capacity and health-related quality of life.

Keywords: Pulmonary disease, chronic obstructive/rehabilitation; Pullmonary diseases, chronic obstructive/psychology; Anxiety; Depression; Quality of Life; Exercise therapy

Objective: To determine the principal adverse effects of the tuberculosis treatment regimen recommended by the Brazilian Ministry of Health. Methods: A prospective descriptive study involving 79 tuberculosis patients treated at the Clinical Research Center of the Cassiano Antonio Moraes University Hospital, in the city of Vitória, Brazil, between 2003 and 2006. The treatment regimen consisted of isoniazid, rifampicin, pyrazinamide and ethambutol for four months, followed by rifampicin and isoniazid for two months. During the treatment period, the patients were clinically evaluated every week and had a monthly medical visit. Results: The overall incidence of adverse effects was 83.54%. Articular/bone/muscle involvement was the most common, followed by skin involvement (24.94% and 22.09%, respectively). Adverse effects were more common in the second month of treatment (41.59%). Modification of the treatment regimen was unnecessary. One patient required concomitant medication to counter the adverse effects. The cure rate was 100%. Conclusions: The overall incidence of adverse effects related to the new treatment regimen recommended by the Brazilian Ministry of Health was high. However, none of those effects demanded a change in the regimen, which was effective in the patients evaluated.

Keywords: Treatment outcome;Tuberculosis; Antitubercular agents; Adverse drug reaction reporting systems.

Objective: To evaluate the effect that the distribution of food baskets to tuberculosis (TB) patients has on treatment outcomes at a primary health care clinic. Methods: Retrospective comparative study of the medical and social aspects of 142 patients at a primary health care clinic in the city of Duque de Caxias, Brazil. The patients were divided into two groups: the first group included 68 patients treated with standard regimens (between September of 2001 and December of 2003); and the second group included 74 patients treated with the same regimens but also receiving food baskets on a monthly basis (between January of 2004 and July of 2006). Results: The statistical comparison between the two groups revealed that the cure rate was higher in the group receiving the food baskets (87.1% vs. 69.7%), whereas the rate of noncompliance was markedly lower (12.9% vs. 30.3%). Conclusions: The results indicate that the distribution of food baskets can be a useful strategy to improve compliance with TB treatment at primary health care clinics.

Keywords: Tuberculosis; Nutritional support; Treatment outcome; Ambulatory health services.

Objective: To determine the efficacy of the scoring system, recommended by the Brazilian National Ministry of Health (NMH), for the diagnosis of pulmonary tuberculosis (TB) in children and adolescents, regardless of their HIV status. Methods: This was a cross-sectional analytical study carried out between January of 2002 and December of 2006, involving 239 individuals less than 15 years of age. The patients were divided into four groups: latent TB (LTB group; n = 81); no-TB (NTB group; n = 41); TB group (n = 104); and TB/HIV group (n = 13). We studied the clinical, radiological and laboratory findings according to the scoring system. Results: Reports of fever, cough, asthenia and weight loss for at least two weeks were significantly higher in the TB group (p < 0.0001). The proportion of cases with a history of any contact and household contact with a TB patient was, respectively, 95.0% and 86.1% in the TB group, versus 75.0% and 58.3% in the TB/HIV group. In the TB and TB/HIV groups, respectively, chest X-rays revealed parenchymal alterations in 75.0% and 53.9%, revealing combined parenchymal/lymph node alterations in 18.2% and 30.8%. There were no significant differences among the groups regarding the tuberculin skin test results. In the TB group, 16.3% of the patients were malnourished (p < 0.005 vs. the LTB group). The mean NMH system scores in the LTB, NTB, TB and TB/HIV groups were, respectively, 24.2, 18.5, 45.3 and 41.5. Conclusions: The NMH system scores were significantly higher in the TB and TB/HIV groups than in the other two groups. Therefore, this scoring system was valid for the diagnosis of pulmonary TB in this population, regardless of HIV status.

Keywords: Tuberculosis/diagnosis; HIV seropositivity; Diagnostic techniques and procedures.

Objective: To evaluate the capacity of the criteria described in Complementary Directive SAS/MS 12, issued on November 12, 2002, to identify patients with severe asthma, describing and comparing clinical, functional and treatment data of such patients. Methods: This was a nested case-control study using a structured database for adult asthma outpatients. We defined cases as asthma patients who met the inclusion criteria described in the directive, defining controls as those who did not. We collected and compared data related to the following: demographic characteristics; history of asthma; medications in use; comorbidities; history of tobacco use; number of exacerbations within the last 12 months, asthma-related hospitalizations and intensive care unit admissions within the last 12 months; spirometry; and sputum cytology. Results: The case and control groups consisted of 29 and 31 patients, respectively. The number of asthma exacerbations and emergency room visits within the last 12 months, as well as the number of patients that received at least one pulse of oral corticosteroids, was significantly higher in the case group than in the control group. In addition, prebronchodilator FVC was lower among the cases than among the controls. Furthermore, cytology revealed that eosinophil counts were significantly higher in the induced sputum of cases than in that of controls. Conclusions: The criteria described in the directive are suited to stratifying patients with severe asthma.

Keywords: Asthma; Budesonide; Combined modality therapy.

Objective: To compare clinical, radiological, and laboratory characteristics of individuals with pulmonary tuberculosis co-infected or not with HIV. Methods: A cross-sectional study, in which signs and symptoms were assessed by anamnesis and physical examination in patients hospitalized with pulmonary tuberculosis. The results of sputum smear microscopy and culture for Mycobacterium tuberculosis, as well as hemoglobin levels and CD4+ T-cell counts, were obtained from medical records, and chest X-ray reports were consulted. Results: We included 50 pulmonary tuberculosis patients, who were divided into two groups (HIV-positive and HIV-negative; n = 25 per group). The mean age of the participants was 38.4 ± 10.5 years; 46 (92%) were males; and 27 (54%) were White. Expectoration was presented by 21 (84%) and 13 (52%) of the patients in the HIV-negative and HIV-positive groups, respectively (p = 0.016). Radiological findings of cavitation were present in 10 (43%) and 2 (10%) of the patients in the HIV-negative and HIV-positive groups, respectively (p = 0.016), whereas an interstitial pattern was observed in 18 (78%) and 8 (40%), respectively (p = 0.012). The mean hemoglobin level was 11.1 ± 2.9 g/dL and 9.3 ± 2.2 g/dL in the HIV-negative and HIV-positive groups, respectively (p = 0.015). Conclusions: In our sample of tuberculosis patients, expectoration was less prevalent, hemoglobin levels were lower, and cavitation was less common, as was an interstitial pattern, among those co-infected with HIV than among those without HIV co-infection.

Keywords: HIV; Tuberculosis; Acquired immunodeficiency syndrome.