ww w . r e u m a t o l o g i a . c o m . b r
REVISTA
BRASILEIRA
DE
REUMATOLOGIA
Original
article
Impact
of
rheumatoid
arthritis
in
the
public
health
system
in
Santa
Catarina,
Brazil:
a
descriptive
and
temporal
trend
analysis
from
1996
to
2009
Rafael
Kmiliauskis
Santos
Gomes
a,b,∗,
Fabio
Antero
Pires
c,
Moacyr
Roberto
Cuce
Nobre
d,
Mauricio
Felippi
de
Sá
Marchi
e,
Jennifer
Cristina
Kozechen
Rickli
eaCentrodeEspecialidadesdoMunicípiodeBlumenau,Blumenau,SC,Brazil
bCentrodeEspecialidadesdoMunicípiodeBrusque,Brusque,SC,Brazil
cUniversidadedeSãoPaulo(USP),FaculdadedeMedicina,UnidadedeSistemasdoServic¸odeInformática,SãoPaulo,SP,Brazil
dUniversidadedeSãoPaulo(USP),FaculdadedeMedicina,UnidadedeEpidemiologiaClínica,SãoPaulo,SP,Brazil
eFundac¸ãoUniversidadeRegionaldeBlumenau(FURB),FaculdadedeMedicina,Blumenau,SC,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received26September2014
Accepted25May2016
Availableonline6October2016
Keywords:
Rheumatoidarthritis
Directcost
Brazil
UnifiedHealthSystem
a
b
s
t
r
a
c
t
Introduction:Therearefewstudiesthatcarriedoutadescriptiveandtrendanalysisbasedon
availabledatafromtheUnifiedHealthSystem(SUS)betweenpre-andpost-freedispensing
ofpharmacologicaltreatmentofrheumatoidarthritis(RA)fromtheperspectiveofthepublic
healthsystem,intermsofthedirectcostofthediseaseamongadultsandelderlyresidents
oftheStateofSantaCatarina,Brazil.Thisstudyaimstocharacterizethedirectcostof
medicalandsurgicalproceduresbeforeandafterthedispensingofdrugsinthisstate.
Methods:Thisisatimeseries-typestudywithacross-sectionalsurveyofdatafromthe
Hospital(SIH)andOutpatient(SIA)InformationSystemofSUSduringtheperiodfrom1996
to2009.
Results:Between1996and2009,thetotalexpenditureforhospital-andoutpatient
phar-macologicaltreatmentofrheumatoidarthritiswasR$26,659,127.20.Afterthedispensingof
drugtreatmentbySUSadecreaseof36%inthenumberofhospitaladmissionswasobserved;
however,anincreaseof19%inclinicalprocedureswasnoted.
Conclusion:Duringtheobservedperiod,areductioninthenumberofhospitaladmissions
forbothclinicalandorthopedicsurgicalproceduresrelatedtothisdiseasewasobserved.
Nevertheless,therewasanincreaseinthecostofmedicaladmissions.
©2016ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND
license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗ Correspondingauthor.
E-mail:[email protected](R.K.Gomes).
http://dx.doi.org/10.1016/j.rbre.2016.07.003
2255-5021/©2016ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/
Impacto
da
artrite
reumatoide
no
sistema
público
de
saúde
em
Santa
Catarina,
Brasil:
análise
descritiva
e
de
tendência
temporal
de
1996
a
2009
Palavras-chave:
Artritereumatoide
Custodireto
Brasil
SistemaÚnicodeSaúde
r
e
s
u
m
o
Introduc¸ão: Poucos estudos fizeram uma análise descritiva e de tendência dos dados
disponíveisdoSistemaÚnicodeSaúde(SUS)entreosperíodospréepós-dispensac¸ão
gra-tuitadotratamentomedicamentosodaartritereumatoide(AR)sobaperspectivadosistema
públicodesaúdeemtermosdecustodiretodadoenc¸aentreadultoseidososmoradoresdo
EstadodeSantaCatarina,Brasil.Opresentetrabalhotemoobjetivodecaracterizarocusto
diretodeprocedimentosclínicosecirúrgicosanteseapósofornecimentodemedicamentos
noestado.
Métodos: Estudodotiposérietemporalcomlevantamentostransversaisentre1996e2009
dosdadosdoSistemadeInformac¸ãoHospitalar(SIH)eAmbulatorial(SIA)doSUS.
Resultados: Entre1996a2009,ogastototalparaotratamentohospitalare
medicamen-tosoambulatorialda artritereumatoidefoideR$ 26.659.127,20.Apósadispensac¸ãodo
tratamentomedicamentosopeloSUSobservou-sequedade36%donúmerodeinternac¸ões
hospitalares.Entretantonotou-seumaumentode19%nosprocedimentosclínicos.
Conclusão:Noperíodoobservadonotou-seumareduc¸ãodonúmerodeinternac¸ões
hospita-larestantoparaprocedimentosclínicosquantocirúrgicosortopédicosrelacionadasaessa
doenc¸a.Apesardisso,ocorreuumaumentodocustodasinternac¸õesclínicas.
©2016ElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCC
BY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
The World Health Organization (WHO) called the period
2000–2010the“decadeofboneandjoint”duetotheincreasing
prevalenceofrheumaticdiseasesandconsequent
socioecono-micimpacttriggeredbythissituation.1Rheumatoidarthritis
(RA)isasystemicinflammatorydisease thataffects joints,
lungs, heart and other organs.2–4 In Brazil,it is estimated
thattheprevalenceofRArangesfrom0.2to1.0%andhasa
worldwidedistribution.5NewoptionsforRAtreatmenthave
emergedinordertominimizethedamageattributedtothe
disease,includingafasterandmoreresolutiveintervention,
thecombinationofdrugs,andinnovationsinpharmacological
formulations.6
Theinterestinestimatingtheeconomicconsequencesand
theimpactonpublichealthstemmedbythesenewtherapies
emergedfromtherelationshipbetweenthehighcostof
med-icationsandthedirectandindirectclinicalbenefitsachieved
with treatment.7 A bibliographic search on direct costs of
rheumatoidarthritisinBrazilforourpublichealth, heldin
majordatabases,foundalimitednumberofpublicationson
thissubject.8–12
The Brazilian public health system (SUS) provides free
access to treatment of RA, such as disease-modifying
antirheumatic drugs (DMARDs) and the immunobiological
agent,tumornecrosisfactor-alphablocker(anti-TNF-alpha)
–whicharehigh-costdrugs.Ordonnancesof2002and2006
fromtheBrazilianMinistryofHealth(MOH)establishedthat
thepatientshouldhavebeeninuseofatleasttwo
combina-tionsofDMARDswithoutsuccessasapreconditionforthe
provisionofananti-TNFblocker.13 More recently,new
bio-pharmaceuticalswereincludedinthelistofdrugsavailable
forthetreatmentofRA.14
Inmostofthetimes,thetreatmentofRAiscarriedouton
anoutpatientbasis.Nevertheless,studiesshowthatthecost
generatedbyhospitaltreatmentisthemostsignificantpart
oftheexpenseswiththisdisease,rangingfrom55to68%of
thetotalcost,althoughonly10%ofpatientsarehospitalized
annually.15Pharmaceuticalsrepresentasignificantexpense,
especiallyearlyinthedisease,whenhospitalizationsareless
frequent, being thesecond largest componentof expenses
relatedtoRA,accountingforover25%ofthetotal.15
Brazil-ianstudiesusingadministrativedatabasescoveringthedirect
costsofoutpatientand drugtreatmentofRAindicate that
pharmaceuticals accountedfor 68.72%ofthe total amount
spent.16
From asurveyofavailabledatafrom Hospital(SIH) and
Outpatient(SIA) InformationSystem fortheState ofSanta
Catarina(SC),Brazil,weconductedadescriptiveanalysisof
theeconomicimpactofRAinthisstate;Furthermore,wealso
evaluatedthetrendofcostsofthediseaseduringtheyears
1996–2009.Finally,weanalyzedthedirectcostsofthedisease,
fromtheperspectiveofthepublichealthsystem.
Materials
and
methods
Thisisatimeseries-typestudyconductedtoevaluatethecosts
ofrheumatoidarthritisamongadultsandelderlypeople
liv-ingintheStateofSantaCatarina,SouthernRegionofBrazil,
whosesurveydatacovertheperiodfrom1996to2009.
Infor-mationonoutpatientandhospitalanddrugtreatmentofRA
wasobtainedsearchingthewebsiteoftheComputer
Depart-mentofSUS–DATASUSfromMOH,whichisfreelyaccessible,
publicdomaindocuments.Olderadultsofbothgendersand
the10threvisionoftheInternationalClassificationofDiseases
(ICD-10),-10M05-M06,DIAGPRINC.Column,wereenlisted.
Data from the Health Information System (SIS) were
exportedinitsoriginalform(.dbcfile)anddecompressedwith
TabWinprogram,availableatDATASUSwebsite(.dbffile).After
that, theresultswere convertedinto Excelspreadsheets in
ordertoelaborateadatabase,andfiltersforrefiningthedata
andprocessingofinformationofinterestforthestudywere
applied.TheinformationcollectedfromSIHwas:numberof
permitsforhospitaladmissions(AIH)andtotalamountpaid,
availableinVALTOTcolumn,codes78500036(from1996to
2007),and0303090324(from2008to2009),correspondingto
clinicalprocedures forRA,consistingofhospitaltreatment
andmonitoringofinflammatorypolyarthropathies,including
diagnosticand/ortherapeuticarthrocentesis.Hospitalizations
fororthopedicsurgicalproceduresavailablefrom2003were:
39003124–partialhiparthroplasty;39016129–totalhip
arthro-plasty;39022145–totalkneearthroplasty,39003051–shoulder
arthroplasty,39010147–kneesynovialexploration,39011020–
spineosteotomy,39011070–arthroscopiclavage,and39014053
–shoulderarthroplasty. Bothcodes are forprocedures
per-formedandclassifiedinPROCREAcolumn.
TheinformationobtainedfromSIAbeginningin2002was:
number and totalcost ofpermitsforhigh-cost procedures
(APAC)forthemaincodeofthisdiseaseatAPACIDPRIcolumn;
forageatAPAIDDAAAorAPNUIDADEcolumn;andthe
med-icationswereseparated,bothforDMARDsandforanti-TNF,in
APATOTALorAPVLAPcolumn.Duringthisperiod,changes
occurred forabbreviations atageand medicationcolumns.
Thefirstregulatoryordonnance(No.865/2002)regardingdrug
treatmentwasestablishedinNovemberofthesameyear.In
ordertobalancethepre-andpost-medicationsdispensedby
SUS,itwasdecidedtosplitthetimeintotwoperiods:the1st
periodfrom1996to2002,andthe2ndperiod2between2003
and2009,respectively.
Thisstudy was submitted and approvedby the Human
Research Ethics Committee of the Fundac¸ão Universidade
RegionalUniversitydeBlumenau(CEP-FURB)underprotocol
number026/12.
Results
InthestateofSantaCatarinabetweentheyears1996–2009,
thetotalSUSexpenses forhospitalandoutpatientmedical
treatmentofRAwasR$26,659,127.20.Thenumberofhospital
admission permits was 7691, with a corresponding cost
of R$7,212,498.45, representing 27% of total costs. Of this
amount, 6000admissions were due toclinical procedures,
accountingfor78%ofallproceduresperformed,withcostsof
R$1,144,402.08,representingonly15.9%ofhospitalexpenses
with the disease, when compared to orthopedic surgical
procedures, even considering that these latter procedures
wereonlybookedfrom2003.Onecanobservethatbeforeand
after the administration ofthe pharmacologicaltreatment
bySUS,adecreasingtrendof36%wasnotedinthenumber
ofadmissionsduetoclinicalissues;thisdownwardtrend(of
28%) was also observed inorthopedic surgical procedures.
With regard to costs, there was a 19% increase in clinical
0.00 20 000.00 40 000.00 60 000.00 80 000.00 100 000.00 120 000.00 140 000.00 0 100 200 300 400 500 600 700 800 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996
Number of clinical procedures
Clinical procedure costs
Linear (number of clinical procedures)
Fig.1–Trendsinthenumberandcostofhospital
admissionsformedicalproceduresforpatientswith
rheumatoidarthritisinSantaCatarina,Brazil,between 1996and2009inadultsandelderlyindividuals.Clinical
procedure–treatmentandfollow-upofinflammatory
polyarthropathies,includingdiagnosticand/ortherapeutic arthrocentesis.
0
2003 2004 2005 2006 2007 2008 2009 50 100 150 200 250 300 350 0.00 200 000.00 400 000.00 600 000.00 800 000.00 1 000 000.00 1 200 000.00 1 400 000.00
Number of orthopedic surgical procedures Orthopedic surgical procedure costs
Linear (number of orthopedic surgical procedures)
Fig.2–Trendsinthenumberandcostofhospital
admissionsfororthopedicsurgicalproceduresforpatients withrheumatoidarthritisinSantaCatarina,Brazil, between2003and2009inadultsandelderlyindividuals.
Orthopedicprocedure–knee,hipandshoulder
arthroplasty,kneesynovialexploration,spineosteotomy, andarthroscopiclavage.
procedures;however,thisincreasewasoffsetbyadecrease
of32%oforthopedicprocedures(Figs.1and2).
Intheoutpatientscenario,thetotalnumberofhigh-cost
procedurepermits(APAC)forthepharmacologicaltreatment
ofthisdiseasewas40,188,atthecostofR$19,446,628.75,
cor-respondingtothebiggestpartofthetotalexpenditurewith
rheumatoidarthritis.Only14.7%ofthetotalnumberofAPACs
hadbeenallocatedtothegroupofanti-TNFagents,butthese
drugsrepresentedapproximately82%ofthefinalcostof
phar-macologicaltreatment,thatis,R$15,975,767.24(Table1).
Discussion
This study found that a change occurred in the profileof
direct costs ofRA inthe time interval of14 years,with a
progressiveincreaseincostsrelatedtopermitsforhigh-cost
procedures with reference to the pharmacological
Table1–Totalnumberandcost(inR$)ofhigh-costprocedurepermitsforrheumatoidarthritisinSantaCatarina,Brazil, from2003to2009foradultsandelderlyindividuals.
Year Numberofhigh-costprocedurepermits(n) Costofhigh-costprocedurepermits(R$)
Totalnumber DMARD Anti-TNF Var.(%) Totalcost DMARD Anti-TNF Var.(%)
2003 410 380 30 – 318,324.67 21,883.74 296,440.93 –
2004 966 894 72 2.35 468,530.65 77,823.78 390,706.87 1.47
2005 2638 2469 169 2.73 892,556.33 176,000.37 716,555.96 1.90
2006 2787 2673 114 1.05 661,825.66 149,505.46 512,320.20 0.74
2007a 43 43 0 – 3376.24 3376.24 0 –
2008 15,838 13,835 2003 – 7,707,046.64 1,564,400.13 6,142,646.51 –
2009 17,506 14,729 2777 1.10 9,394,958.56 1,477,871.79 7,917,096.77 1.21
Total 40,188 35,023 5165 19,446,628.75 3,740,861.51 15,975,767.24
Anti-TNF,anti-tumournecrosisfactor;DMARD,disease-modifyingantirheumaticdrug. a NodataavailableintheOutpatientInformationSystem(SIA/SUS).
immunobiologicalagentsdispensed,the expenseswiththe
pharmacologicaltreatmentofRAaccountedformostofthe
financialchargesforthisdisease.Asforhospitaladmissions
–thesecondlargestdirectcostofthedisease,thenumberof
admissionpermitsbyclinicalprocedureshowedasignificant
downwardtrendafterthefreeaccesstodrugtreatmentby
SUS.Orthopedicsurgicalproceduresalsoshowedadecrease
inthenumberofpermitsandalsoincosts.
Medicalconsultationrepresentsthelowestpercentageof
thetotalcostofthedisease,whencomparedtohospitaland
drugcosts,rangingbetween10–25%.15 Similarfindingsina
study conductedin Argentina in 2002(in the prebiological
era)indicatedthattheadmissionsaccountedfor73%ofthe
totaldirectcost,whiledrugsandoutpatientprocedures
rep-resented16%and8%,respectively.17Inastudyconductedin
Germany,itsauthorsfoundthatoverhalfofthemedication
costswasattributedtoimmunobiologicalagents;however,the
costsassociatedwithrheumatoidarthritiswereunchanged
throughoutthe study period.Thisonly occurred thanksto
thecompensationoftheincreaseindrugexpensesandtothe
lowerhospitalizationexpendituresandproductivitycosts.18
Amulticentercross-sectionalstudywith1109participants
conductedin2000inFranceestablishedthatthe main
rea-sonforhospitalizationwasthediseaseitself,19,20evenwitha
moreappropriatecontroloftheinflammatoryactivityofRA,
demonstrablyachieved withan earlyand aggressive
treat-ment with synthetic drugs (alone or in combination with
immunobiological agents).21,22 Thedecrease of 36% in the
numberofhospitalclinicaladmissionsasaresultofRA,found
inourstudywhencomparingthe2ndversus1stperiod,is
cor-roboratedbyastudybasedonaSouthernregionofSweden
databaseinaperiodof10years,whereadecreaseof27%and
28%formenandwomen,respectively,wasobserved.Itwas
alsonotedadecreaseof28%inthenumberof
hospitaliza-tionsfororthopediccauses,comparedwith39%and36%of
Swedishmenandwomen,respectively.22Similarly,acohort
studyconductedinGermanycomparingthecostsof
hospital-izationsintheperiodswithoutversuswithimmunobiological
agents(anti-TNF)showedadecrease,intermsofcosts,from
29%to13%18–differentlyfromtheincreaseof19%incostsin
ourresultsforclinicaladmissions.
Accordingtotheauthors,thedirectcostforhospitalization
andmedicationsrepresentssomethingbetween70%and80%
ofthetotalcostofthedisease,23,24ofwhichthegreaterportion
is relatedto the pharmacologicaltreatmentof rheumatoid
arthritis,especiallywithimmunobiologicalagents(anti-TNF),
overcomingtheexpensesonhospitalizations.25 AUS
longi-tudinal,three-year(1999–2001)studywith7527participants
showedthatthedirectcostofmedicationsrepresented66%
ofthetotalcost,asubstantiallyhigherpercentagewhen
com-paredwiththefindingsofthepre-immunobiologicalera;and
only 25%of subjectshad been receivingimmunobiological
agents.26 Another2009studyinSouthKorea,whichuseda
nationaldatabase,estimatedthatthecostofmedicationswas
approximately 48.6%;according toits authors, this cost is
directlyrelatedtotheimmunobiologicaltherapy.27Theresult
of this study points in the same direction, in that 73% of
expenditureswereallocatedtopharmaceuticals,even
consid-ering the use of only14.7% of anti-TNF agents. Just as in
Brazil,otherdevelopingcountriessuchasColombiaand
Mex-ico establishedthat pharmaceuticals constitute the largest
componentofthetotaldirectcost.28,29
Thisstudyhassomelimitationsinherenttothefactthat
weusedasecondarydatabaseforthecollectionofinformation
foritsconduction,whichcandeterminethatthecostsmaybe
higherthanthosereported,sincemanySISdataare
under-reportedor aresimplylostalong theconsolidationflow,as
occurred,forexample,in2007,withreferencetothenumber
andtotalcostofthehigh-costprocedurepermits.Moreover,
thisformofdatacollectiondoesnotallowthatonebecomes
awareoftheindividualcharacteristics,forexample,disease
duration,diseaseseverity(fromthemilderforms,whichhave
alowerriskofhospitalizationorofanorthopedicsurgical
pro-cedure,tothemostserioussituations);thedeterminationof
whatwerethetherapeuticregimensadministeredthroughout
thedisease;thepresenceofcomorbidconditions;and
activ-ityindicesforthisdisease,inadditiontoaregularaccessto
healthcareunitprovidingaspecialist.Itisworth
emphasiz-ing thatthis studymayhavebeeninfluencedinitsresults,
duetothedecreaseinthenumberofhospitalbedsoffered
bySUSinthestateofSantaCatarina–from12,750in2005
to11,175in2009(www.sc.ripsa.org.br;siteaccessedonJuly
31,2013).Incontrast,aBrazilianstudywith12,218,632
hos-pitaldischarges in 1998(datafrom SIH/SUS) evaluated the
existenceofinconsistencieswithrespecttodiagnostic,
thetotalinconsistenciesforthesethreevariableswereunder
0.5%,i.e.anegligibleerror.30
Another limitation concerns the characteristics of
eco-nomic evaluation studies. It should be borne in mind the
difficultyofcomparingcostsbetweencountrieswithdifferent
economicsituations,especiallyamongdevelopedand
devel-opingcountries,andalsothemonetaryvalueoflocalcurrency,
whichundergoeschangesovertime,duetoitsexchangerate.
Furthermore,themonetarydataobtainedthroughananalysis
ofinformationsystemsrefertoSUSchargesorexpenses,with
noinformationbasedontotalcosts forgoods andservices
consumedinthehealthcareservice.
Theknowledgeofthedistributionofthetotaldirectcostof
RAleadstoabetteruseofresources;besides,thisknowledge
pointstowhataretheareasofhealthcarewhereresourcescan
besaved.Despitethedownwardtrendobservedinthe
num-berofhospitaladmissions(bothforclinicalreasonsandfor
anorthopedicsurgery)relatedtoRAsincetheavailabilityof
freemedicalcareofferedbytheBrazilianNationalHealth
Sys-tem,thestudyindicatesthattheratiobetweenthehighcost
ofmedicationsandtheeffectivenessinreducing
hospitaliza-tionsstilltendstoholdanunfavorableratio.Itissuggested
thatnewstudiesformonitoringdatabasesfromhealth
infor-mationsystems,resultinginalong-termeconomicanalysis,
beregularlycarriedout,inordertorecommendnew
possibil-itiesforreducingthedirectcostsofRA.
Funding
Fundac¸ãodeAmparoàPesquisadoEstadodeSãoPaulo,
pro-cessFAPESP2013/12979-1.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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s
1. GomesRS,PeresKG.Desigualdadessocioeconômicase demográficascomofatoresderiscoparaaartrite
autorreferida:estudodebasepopulacionalemadultosnoSul doBrasil.CadSaúdePública.2012;28:1506–16.
2. PollardL,ChoyEH,ScottDL.Theconsequencesofrheumatoid arthritis:qualityoflifemeasuresintheindividualpatient. ClinExpRheumatol.2005;235Suppl.39:S43–52.
3. SchoelsM,WongJ,ScottDL,ZinkA,RichardsP,LandewéR, etal.Economicaspectsoftreatmentoptionsinrheumatoid arthritis:asystematicliteraturereviewinformingtheEULAR recommendationsforthemanagementofrheumatoid arthritis.AnnRheumDis.2010;69:995–1003.
4. ScottDL,PugnerK,KaarelaK,DoyleDV,WoolfA,HolmesJ, etal.Thelinksbetweenjointdamageanddisabilityin rheumatoidarthritis.Rheumatology.2000;39:122–32.
5. MarquesNetoJF,Gonc¸alvesET,LangenLFOB,CunhaMFL, RadominskiS,OliveiraSM,etal.Multicentricstudyofthe prevalenceofadultrheumatoidarthritisinBrazilian populationsamples.RevBrasReumatol.1993;33:169–73.
6. PincusT.Theunderestimatedlongtermmedicaland economicconsequencesofrheumatoidarthritis.Drugs. 1995;50Suppl.1:1–14.
7.KobeltG,EberhardtK,GeborekP.TNFinhibitorsinthe treatmentofrheumatoidarthritisinclinicalpractice:costs andoutcomesinafollowupstudyofpatientswithRAtreated withetanerceptorinfliximabinsouthernSweden.Ann RheumDis.2004;63:4–10.
8.ChermontGC,KowalskiSC,CiconelliRM,FerrazMB.Resource utilizationandthecostofrheumatoidarthritisinBrazil.Clin ExpRheumatol.2008;26:24–31.
9.MoraisAD,PereiraML.Costminimizationofanti-TNF biologicsinthetreatmentofrheumatoidarthritis,ankylosing spondylitisandpsoriaticarthritisintheBrazilianPublic HealthCareSystem.ValueHealth.2012;15:A36.
10.WiensA,GrochockiMC,PontarolliDRS,VensonR,CorrerCJ, PontaroloR.Profileofusersofanticytokinesofferedbythe healthcaresysteminthestateofParanáforthetreatmentof rheumatoidarthritis.RevBrasReumatol.2012;52:203–13.
11.SaggiaMG,SantosEA,BorgesLG,AguiarR.Realworld databaseanalysis:usageandeconomicimpactofanti-TNF’s assecondlinetherapyforrheumatoidarthritispatientsinthe publichealthcaresectorinBrazil.ValueHealth.2009;12:A451.
12.MonteiroRDC,ZaniniAC.Costanalysisofdrugtherapyin rheumatoidarthritis.RevBrasCiêncFarm.2008;44:25–33.
13.ProtocoloClínicoeDiretrizesTerapêuticas–Artrite
Reumatóide.PortariaSAS/MSn◦865de05denovembrode
2002ePortariaSCTIEn◦66de06denovembrode2006.
Availablefrom:http://www.portal.saude.gov.br/portal/
arquivos/pdf/pcdtartrite reuma.toide2006.pdf[accessed 24.08.12].
14.MinistériodaSaúde.SecretariadeCiência,Tecnologiae
InsumosEstratégicos.DepartamentodeAssistência
FarmacêuticaeInsumosEstratégicos.Coordenac¸ãoGeraldo
ComponenteEspecializadodaAssistênciaFarmacêutica.
OfícioCircularn.◦13/2013/CGCEAF/DAF/SCTIE/MSde03de
julhode2013.Availablefrom:http://www.portal.saude.gov.
br/portal/arquivos/pdf/oficiocircularcgceaf132013.pdf
[accessed15.07.13].
15.DeborahP,LubeckA.Reviewofthedirectcostsofrheumatoid arthritis.Pharmacoeconomics.2001;19:811–8.
16.CostaJO,AlmeidaAM,JuniorAAG,CherchigliaML,Andrade EIG,AcurcioFA.TratamentodaartritereumatoidenoSistema ÚnicodeSaúde,Brasil:gastoscominfliximabeem
comparac¸ãocommedicamentosmodificadoresdocursoda doenc¸asintéticos,2003a2006.CadSaúdePública.
2014;30:283–95.
17.CatayE,DelCidCC,NarváezL,VelozoEJ,RosaJE,CatoggioLJ, etal.Costofrheumatoidarthritisinaselectedpopulation fromArgentinaintheprebiologictherapyera.Clinicoecon OutcomesRes.2012;4:219–25.
18.KirchhoffT,RuofJ,MittendorfT,RihlM,BernateckM,MauW, etal.CostofillnessinrheumatoidarthritisinGermanyin 1997–98and2002:costdriversandcostsavings.
Rheumatology.2011;50:756–61.
19.GuilleminF,DurieuxS,DaurèsJP,LafumaA,SarauxA,Sibilia J,etal.CostsofrheumatoidarthritisinFrance:amulticenter studyof1109patientsmanagedbyhospital-based
rheumatologists.JRheumatol.2004;31:1297–304.
20.Pineda-TamayoR,ArcilaG,RestrepoP,AnayaJM.Impactof cardiovascularillnessonhospitalizationcostsinpatients withrheumatoidarthritis.Biomedica.2004;24:366–74.
21.MetsiosGS,Stavropoulos-KalinoglouA,TreharneGJ,Nevill AM,SandooA,PanoulasVF,etal.Diseaseactivityandlow physicalactivityassociatewithnumberofhospital admissionsandlengthofhospitalisationinpatientswith rheumatoidarthritis.ArthritisResTher.2011;13:R108.
23.LajasC,AbasoloL,BellajdelB,Hernández-GarcíaC,Carmona L,VargasE,etal.Costsandpredictorsofcostsinrheumatoid arthritis:aprevalence-basedstudy.ArthritisRheum. 2003;49:64–70.
24.ClarkeAE,ZowallH,LevintonC,AssimakopoulosH,SibleyJT, HagaM,etal.Directandindirectmedicalcostsincurredby Canadianpatientswithrheumatoidarthritis:a12yearstudy. JRheumatol.1997;24:1051–60.
25.FautrelB,Gaujoux-VialaC.Medicalandeconomicaspectsof rheumatoidarthritis.BullAcadNatlMed.2012;196:
1295–305.
26.MichaudK,MesserJ,ChoiHK,WolfeF.Directmedicalcosts andtheirpredictorsinpatientswithrheumatoidarthritis:a three-yearstudyof7,527patients.ArthritisRheum. 2003;48:2750–62.
27.KwonJM,ChoSK,KimJH,LeeEK.MedicalcostsforKorean patientswithrheumatoidarthritisbasedonthenational claimsdatabase.RheumatolInt.2012;32:2893–9.
28.MoraC,GonzálezA,DíazJ,QuintanaG.Financialcostofearly rheumatoidarthritisinthefirstyearofmedicalattention: threeclinicalscenariosinathird-tieruniversityhospitalin Colombia.Biomedica.2009;29:43–50.
29.Mould-QuevedoJ,Peláez-BallestasI,Vázquez-MelladoJ, Terán-EstradaL,Esquivel-ValerioJ,Ventura-RíosL,etal. Socialcostsofthemostcommoninflammatoryrheumatic diseasesinMexicofromthepatient’sperspective.GacMed Mex.2008;144:225–31.
