SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Original
Article
Rotator
cuff
repair
in
the
Brazilian
Unified
Health
System:
Brazilian
trends
from
2003
to
2015
夽
Eduardo
Angeli
Malavolta,
Jorge
Henrique
Assunc¸ão
∗,
Rodrigo
Alves
Beraldo,
Gustavo
de
Mello
Ribeiro
Pinto,
Mauro
Emilio
Conforto
Gracitelli,
Arnaldo
Amado
Ferreira
Neto
UniversidadedeSãoPaulo,FaculdadedeMedicina,HospitaldasClínicas,SãoPaulo,SP,Brazil
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t
i
c
l
e
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n
f
o
Articlehistory:
Received19May2016 Accepted7July2016 Availableonline5July2017
Keywords:
Rotatorcuff Shoulder Publichealth Healthpolicy
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Objective:ToassessthehistoricaltrendofrotatorcuffrepairsinBrazilbetween2003and 2015,usingthedatabaseoftheBrazilianUnifiedHealthSystem’s(SistemaÚnicodeSaúde [SUS])DepartmentofInformatics(DataSUS).
Methods:HistoricalseriesusingDataSUS.Surgeriesperformedbetween2003and2015were includedanddatarelatingtocufftearrepairwereassessed,includingdecompression pro-cedureswereincluded.Thenumeratorwasthetotalnumberofrotatorcuffrepairandthe denominator,thetotalpopulationoftheassessedlocality.Populationdatawerebasedon informationfromtheInstitutoBrasileirodeGeografiaeEstatística(IBGE).
Results:Duringtheperiod,50,207surgerieswereperformed.Theratewaspresentedas num-berofproceduresper100,000inhabitants,andincreasedfrom0.83to2.81,agrowthof238%. In2015,theSouthregionhadthehighestrate,6.32,followedbytheSoutheast,3.62,while theNorthhadthelowestrate,0.13.ThegrowingtrendcanbeobservedintheSoutheast, South,andMidwest,whiletherateisstableintheNorthandNortheast.
Conclusion: TherateofrotatorcuffrepairsinBrazilperformedthroughtheSUSincreased from0.83to2.81between2003and2015,representingagrowthof238%,butremainslower thanthatofdevelopedcountries.AtrendofgrowthcanbeobservedintheSoutheast,South, andMidwest,whiletherateisstableintheNorthandNortheast.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
夽
StudyconductedattheUniversidadedeSãoPaulo,FaculdadedeMedicina,HospitaldasClínicas,InstitutodeOrtopediae Trauma-tologia,GrupodeOmbroeCotovelo,SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:[email protected](J.H.Assunc¸ão). http://dx.doi.org/10.1016/j.rboe.2017.06.010
Reparo
do
manguito
rotador
no
Sistema
Único
de
Saúde:
tendência
brasileira
de
2003
a
2015
Palavras-chave:
Manguitorotador Ombro
Saúdepública Políticadesaúde
r
e
s
u
m
o
Objetivo: AvaliaratendênciahistóricadereparosdomanguitorotadornoBrasil,entre2003 e2015,comousodobancodedadosdoDepartamentodeInformáticadoSUS(DataSUS).
Métodos: SériehistóricacomousodoDataSUS.Foramincluídascirurgiasfeitasentre2003 e2015ecoletadososdadosreferentesaoreparoderoturadomanguito,incluindo procedi-mentosdescompressivos.Usamoscomonumeradorototaldereparosdomanguitorotador ecomodenominadorapopulac¸ãototaldalocalidadeavaliada.Dadospopulacionaisforam baseadosnasinformac¸õesdoInstitutoBrasileirodeGeografiaeEstatística(IBGE).Astaxas foramapresentadasporgrupode100.000habitantes.
Resultados: Duranteoperíodo,foramregistradas50.207cirurgias.Ataxaaumentoude0,83 para2,81,umacréscimode238%.Em2015,a RegiãoSul apresentouamaiortaxa,6,32, seguidadaSudeste,3,62,enquantoaNorteapresentouamenortaxa,0,13.Atendência crescentepodeserobservadanasregiõesSudeste,SuleCentro-Oeste,enquantooíndiceé estávelnasregiõesNorteeNordeste.
Conclusão: AtaxadereparosdomanguitorotadornoBrasilfeitospeloSistemaÚnicode Saúdeaumentoude0,83para2,81entre2003e2015,umaumentode238%,maspermanece inferioràdospaísesdesenvolvidos.Umatendênciacrescentepodeserobservadanasregiões Sudeste,SuleCentro-Oeste,enquantoataxaéestávelnasregiõesNorteeNordeste.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Shoulderpainhasahighprevalenceinthepopulation,ranging from7%to26%.1Rotatorcuffdisorders,themaincauseofpain intheshouldergirdle,affects20%ofthegeneralpopulation andupto50%ofindividualsolderthan80years.2Rotatorcuff repairisthemainreasonforshouldersurgery.3
Thissurgeryprovidessatisfactoryclinicalresultsinmore than85%ofpatients.4–8However,thetrendofincreaseinthe numberofrotatorcuffrepairs,from31%to238%inpublished historical series,9–14 increases expenses of the healthcare system.14 Thus, it is necessary to outline the Brazilian panoramatodeterminepublicpoliciesthatbestservethe pop-ulation.InBrazil,therehavebeennoevaluationsofthe num-berofsurgeriesperformedfortherepairofrotatorcufftears. Theprimaryobjectiveofthisstudywastoevaluatethe his-toricaltrendofrotatorcuffrepairsperformedbytheBrazilian PublicHealthSystem(SistemaÚnicodeSaúde[SUS])between 2003and2015,usingthedatabaseoftheDepartmentof Infor-mationTechnologyofSUS(DataSUS).Thesecondaryobjective was to describe the rate of accredited services and asso-ciatemembersoftheBrazilianSocietyofShoulderandElbow Surgery(SociedadeBrasileiradeCirurgiadoOmbroeCotovelo [SBCOC])byregionin2015andtocorrelatethisdatawiththat oftheratesofsurgeries.
Methods
A historical series was made using the database of the DataSUS, an agency of the Department of Strategic and
ParticipatoryManagementoftheMinistryofHealth respon-sible for collecting, processing, and disseminating health information. All data collected are freely available on the DataSUS website.15 Surgeriesperformed between2003 and 2015 were included, and data for the cuff tear repair pro-cedure,includingdecompressionprocedures,werecollected. Thisstudywasapprovedbytheinstitution’sResearchEthics CommitteeunderNo.1193.
Theprimaryobjectiveofthestudywastodescribethe inci-denceofrotatorcuffrepairsper100,000inhabitants/year,in nationaltermsandstratifiedbyregionandstateofthe feder-ation.Thedatawerestratifiedbyyear,from2003to2015.To calculatetheincidence,thetotalnumberofrotatorcuffrepairs wasusedasnumerator;thetotalnationalpopulation,region, orstatefortheperiodstudiedwasusedasthedenominator. Populationdatafromthe2010NationalCensuswerecollected ontheBrazilianInstituteofGeographyandStatistics(Instituto BrasileirodeGeografiaeEstatística[IBGE])website,16aswellas thepopulationprojectionsfortheremainingyears.17Therate ofaccreditedservicesandassociatemembersofSBCOCwas basedon theinformationfrom theSociety’swebsite,18 and confirmedbytheofficialsector.Forthisanalysis,the denom-inator usedwasthe populationin2015and therates were presentedper10,000,000inhabitants.
Statisticalanalysis
4
3
2
1 0.83 1.11
1.30 1.50
1.67 1.87 1.97
2.16 2.21 2.50
2.84 2.96 2.81
2015 201
4 2013 2012 201
1 2010 2009 2008 2007 2006 2005 2004 2003 0
Fig.1–Ratesofrotatorcuffrepairsperformedinthe BrazilianPublicHealthSystemfrom2003to2015(per 100,000inhabitants).
Norte
8
6
4
2
0
2003 2004 2005 2006 2007 2008 200 9
2010 2011 2012 2013 2014 2015 Nordeste Centro-Oeste Sudeste Sul
Fig.2–Ratesofrotatorcuffrepairsperformedinthe BrazilianPublicHealthSystem,perregion,from2003to 2015(per100,000inhabitants).
waspresentedper10,000,000inhabitants.Theincidencewas basedontheanalysisoftheentireBrazilianpopulation;itwas notnecessarytocalculatetheconfidenceinterval.
Results
Duringthe13yearsincludedinthestudy,50,207rotatorcuff repairswereperformedandregisteredintheSUS.Therateof proceduresper100,000inhabitantsrosefrom0.83to2.81in theperiod,anincreaseof238%(Fig.1).
In2015,thehighestrateofsurgerieswasobservedinthe Southregion(6.32procedures/100,000inhabitants),followed bytheSoutheast,with3.62.Inturn,theNorthregionpresented thelowestrate,0.13.Atrendofincreasecouldbeobservedin theSoutheast,South,andMid-Westregions, whiletherate wasstableintheNorthandNortheastregions(Fig.2).
Table1presentsthehistoricaldataonrotatorcuffrepair
ratesperstatefrom2003to2015.Thecompletesetofdata,
includingtheabsolutenumberofsurgeriesandthe popula-tion ofthe stateandregionineachyear,are showninthe SupplementaryTable,availableontheonlineversion.In2015, thestateswiththehighestratesofrotatorcuffrepairwere EspíritoSanto(11.96),RioGrandedoSul(8.95),Paraná(4.87), andSantaCatarina(4.36).AllstatesintheNortheastregion, exceptforPiauí,andallthoseintheNorthregionpresented rateslowerthanonesurgeryper100,000inhabitantsin2015.
Table2presentstherateofaccreditedservicesand
asso-ciatemembersofSBCOCin2015per10,000,000inhabitants.
Discussion
Theanalysisofthenationaldatabaseshowedthat,asinother countries,thereisatrendofincreaseinthenumberofrotator cuffrepairsperformedinBrazil,witha238%increaseinthe periodstudied.Thispercentageissimilartothatreportedby Ensoretal.13inthestateofNewYorkbetween1995and2009, andhigherthantheotherassessedstudies,whichreported increasesbetween31%and204%.9,10,12,14However,therateof proceduresperformedbySUSislowerthaninothercountries. Therateofsurgeriesper100,000inhabitantsincreasedfrom 0.83in2002to2.81in2015.IntheUnitedStates,Colvinetal.19 demonstratedthatthisrateincreasedfrom41to98/100,000 inhabitantsbetween1996and2006.InEngland,Judgeetal.11 reportedarateof6.3/100,000inhabitantsin2009–2010.In Fin-land,Palonevaetal.10reportedanincreaseintherate,from 44 to 131 per 100,000 inhabitants between 1998 and 2011, but only when using the population over 18 years as the denominator. StudiesconductedintheUnitedStatesusing statedatabases13,14includingpatientsundergoingoutpatient surgery3 or subgroups of patients with health insurance12 alsodemonstratedincreasingtrends,butwithhigherrotator cuffrepairratesthanthoseofSUS.Unfortunately,nostudies withalargepopulationsampleindevelopingcountrieswere retrievedtocomparethepresentdatawithaneconomicand socialrealitysimilartothatofBrazil.
Theauthorsbelievethatthelowrateofsurgeriesregistered inBrazilwhencomparedtodevelopedcountriesisduetoa numberoffactors.Thefirstfactormaybeunderreporting,as somestatesdidnotrecordrotatorcuffrepairsurgeryincertain years. Furthermore,the Brazilian population isundergoing anagingprocess,whichhasalready occurredindeveloped countries.20Asrotatorcuffdisordersareage-related,2a pop-ulationwithalowerproportionofolderpeopleisexpected topresentalowerincidenceofrotatorcuffrepairsurgeries. Brazilalsohasremoteareasthatlackmedicalassistance,as wellastheeconomicscenariotypicalofdevelopingcountries, whichsuggeststhatsomepatientsmaynotreceivetheentire recommendedtreatment.
Table1–RotatorcuffrepairratesintheBrazilianPublicHealthSystem,perstate,from2003to2015(per100,000 inhabitants).
State/region 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Acre 0.16 0.00 0.00 0.15 0.00 0.71 0.14 0.82 0.94 0.00 0.00 0.25 0.37
Amapá 0.00 0.00 0.00 0.00 0.00 0.31 0.00 0.15 0.00 0.00 0.41 0.13 0.78
Amazonas 0.10 0.19 0.34 0.30 0.12 0.40 0.31 0.23 0.03 0.08 0.13 0.08 0.13
Pará 0.15 0.13 0.09 0.45 0.74 0.42 0.57 0.28 0.06 0.03 0.13 0.14 0.09
Rondônia 0.07 0.00 0.00 0.06 0.00 0.12 0.00 0.06 0.12 0.06 0.12 0.00 0.00
Roraima 0.00 0.00 0.00 0.72 0.00 0.23 0.00 0.00 0.00 0.21 0.41 0.40 0.20
Tocantins 0.40 0.47 0.15 0.90 0.66 0.29 0.72 0.07 0.00 0.14 0.27 0.13 0.07
Northregion 0.14 0.14 0.14 0.39 0.44 0.38 0.41 0.24 0.09 0.05 0.15 0.12 0.13
Alagoas 0.00 0.10 0.03 0.13 0.32 0.28 0.31 0.19 0.34 0.12 0.03 0.06 0.03
Bahia 0.44 0.44 0.73 0.77 0.78 0.71 0.68 0.99 1.16 1.41 1.32 0.96 0.87
Ceará 0.26 0.26 0.38 0.38 0.40 0.40 0.25 0.37 0.31 0.41 0.59 0.43 0.61
Maranhão 0.13 0.08 0.14 0.17 0.25 0.17 0.02 0.11 0.30 0.22 0.25 0.32 0.29
Paraíba 1.51 1.44 0.69 0.79 1.37 0.99 1.03 0.64 0.16 0.33 1.33 2.03 0.65
Pernambuco 0.24 0.29 0.42 0.42 0.26 0.34 0.18 0.27 0.42 0.28 0.28 0.23 0.36
Piauí 0.24 0.80 0.36 0.62 0.19 0.68 1.18 1.03 1.08 1.04 1.16 0.56 1.31
RioGrandedoNorte 0.74 0.89 0.98 0.64 0.35 0.06 0.19 0.16 0.03 0.00 0.03 0.06 0.00
Sergipe 0.36 0.56 0.45 0.90 1.37 0.53 0.05 0.05 0.33 0.46 0.32 0.45 0.94
Northeastregion 0.40 0.45 0.49 0.53 0.55 0.48 0.43 0.51 0.58 0.63 0.70 0.60 0.58
DistritoFederal 0.67 1.23 1.55 2.19 1.03 0.93 1.57 1.87 1.91 2.86 3.19 2.87 2.74
Goiás 0.17 0.42 0.85 0.56 0.22 0.72 0.87 0.62 0.78 0.68 1.88 4.40 3.59
MatoGrosso 0.37 0.58 0.46 0.45 0.72 0.68 0.63 0.33 0.39 0.70 0.28 0.40 1.10
MatoGrossodoSul 0.40 0.40 0.43 0.98 1.13 1.53 1.31 0.69 1.15 1.57 1.89 3.13 3.17
Mid-Westregion 0.34 0.59 0.82 0.90 0.63 0.89 1.02 0.80 0.97 1.24 1.79 3.05 2.83
EspíritoSanto 0.57 0.79 0.58 0.69 1.24 1.19 0.03 0.37 1.28 4.80 9.66 10.48 11.96
MinasGerais 0.90 1.16 1.21 1.21 1.25 2.46 2.34 2.64 2.67 3.21 3.57 3.07 2.80
RiodeJaneiro 0.85 1.30 1.41 1.91 1.96 1.44 1.93 1.45 2.24 2.78 3.13 3.37 3.46
SãoPaulo 1.16 1.56 1.85 2.17 2.55 2.99 3.19 3.98 3.60 3.42 3.54 3.59 3.33
Southeastregion 1.01 1.38 1.55 1.82 2.06 2.48 2.60 2.99 3.01 3.31 3.75 3.73 3.62
Paraná 2.19 2.75 3.07 2.92 3.90 4.13 5.27 4.23 4.29 5.88 5.14 4.52 4.87
RioGrandedoSul 1.44 2.00 2.92 4.04 4.20 4.43 4.03 5.05 5.82 5.93 8.43 10.23 8.95 SantaCatarina 1.54 2.43 2.68 2.76 3.39 3.65 4.11 5.12 4.34 5.63 5.40 5.29 4.36
Southregion 1.75 2.38 2.93 3.33 3.91 4.14 4.52 4.75 4.90 5.84 6.47 6.90 6.32 Brazil 0.83 1.11 1.30 1.50 1.67 1.87 1.97 2.16 2.21 2.50 2.84 2.96 2.81
Boldlinesthatinformtherateofsurgeriesbyregionandthetotaloftheentirecountry.Theothersthatrepresentthestatesarenotinbold. BoldindicatesthetotalsoftheregionsofBrazil.
Table2–Rateofaccreditedservicesandassociated
membersoftheBrazilianSocietyofShoulderandElbow
Surgery(SociedadeBrasileiradeCirurgiadoOmbroe Cotovelo[SBCOC])perBrazilianregionin2015(per 10,000,000inhabitants).
Region SBCOCaccredited services
Associatedmembers SBCOC
North 0 10.87
Northeast 0.35 19.98
Mid-West 1.3 41.44
Southeast 1.98 59.25
South 1.71 44.82
Thepresentstudyhassomelimitations.Theauthorschose toexcludetheinitialperiodavailableinthedatabase(from 1992to2002).ThenumberofsurgeriesperformedinBrazil, accordingtoDataSUS,rangedfrom76to251peryearinthe
excludedperiod.Fromthatdateonwards,thenumberswere
closertothereality.Theauthorsattributethistoapossible collectionbias.Itisnoteworthythattheanalysisconsidered wheresurgerytookplace,notwherethepatientdwells.The intentionbehindthisstrategywastoassesstheimportance ofeachstateinthetotalsurgicalvolume.
TheDataSUSdatabasedoesnotincludepatientscovered
by supplementary health care. Approximately 25% of the
Brazilianpopulationhasaccesstosomekindofhealth
insur-ance, according to data on the website of the National
Supplementary Health Agency (AgênciaNacionalde Saúde
Asfavorablepoints,itisnoteworthythat,tothebestofthe authors’knowledge,thisisthefirstBrazilianpopulationstudy toassesstheincidenceofrotatorcuffrepairsandthefirstto usetheDataSUSdatabaseinorthopedics.Inaddition,ithas shownthattherateofsurgeriesinBrazilislowerthanthat ofdevelopedcountries.Thus,despitethepossiblecollection biases,theauthorsbelievethatalargepartofthepopulation remainsunassistedinrelationtothisprevalentclinical condi-tion.TheauthorsbelievethatthisstudycanguideSUSactions inregardtocontinuingmedicaleducationprogramsandbetter distributionofresources.
Conclusions
InBrazil,therateofrotatorcuffrepairsperformedbySUSper 100,000inhabitantsincreasedfrom0.83to2.81between2003 and2015,anincreaseof238%.TheSouthregionpresentedthe highestrateofsurgeries,6.32,followedbytheSoutheast,with 3.62.Inturn,theNorthregionpresentedthelowestrate,0.13. Theincreasingrateofprocedurestrendcouldbeobservedin theSoutheast,South,andMid-Westregions, whiletherate wasstableintheNorthandNortheastregions.Theregions withlowerrotatorcuffrepairrates,NorthandNortheast,have thelowestratesofaccreditedservicesandassociated mem-bersoftheBrazilianSocietyofShoulderandElbowSurgery.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Appendix
A.
Supplementary
data
Supplementarydataassociatedwiththisarticlecanbefound, intheonlineversion,atdoi:10.1016/j.rboe.2017.06.010.
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